mtiieCitpoflrmgork 
College  of  ^fjpgiciansi  ant  ^urgeontf 


Xitirarp 


2  ».»B?.AR*tS  ^ 


O 


.O 


'♦*.-         .V 


HEALTH 
SCIBUCES 
LIBKAKY 


MENSTRUATION 

AND 

ITS  DISORDERS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/menstruationitsdOOnova 


MENSTRUATION 

AND 

ITS   DISORDERS 


BY 


EMIL  NOVAK,  A.B.,  M.D.,  F.A.C.S. 

INSTRUCTOR   IN    CLINICAL   GYNECOLOGY, 

JOHNS    HOPKINS    UNIVERSITY, 

BALTIMORE,    MARYLAND 


GYNECOLOGICAL  AND  OBSTETRICAL  MONOGRAPHS 


WITH  FORTY  ILLUSTRATIONS 


D.  APPLETON  AND  COMPANY 


NEW  YORK 


LONDON 


1921 


COPYRIGHT,   1921,  BY 

D.  APPLETON  AND  COMPANY 


n 


FEINTED  IN  THE  UNITED  STATES  OF  AUBRICA 


TO 
HOWARD  A.  KELLY, 

EMERITUS   PROFESSOR   OF  GYKECOLOGT 

JOHNS   HOPKINS   UNIVERSITY 

MASTER   GYNECOLOGIST 

THIS  BOOK  IS  DEDICATED 

AS  A   TOKEN   OF   GRATITUDE   AND   ESTEEM 


PREFACE 

It  is  probably  not  an  exaggeration  to  say  that  we  have  learned  more  con- 
cerning the  nature  and  mechanism  of  the  menstrual  phenomenon  during  the 
past  fifteen  or  twenty  years  than  during  many  centuries  preceding.  This  new 
knowledge  has  been  an  important  factor  in  the  more  intelligent  treatment  of 
the  disorders  of  menstruation,  which  constitute  a  not  inconsiderable  pro- 
portion of  the  ailments  encountered  by  every  general  practitioner.  The 
gynecologist  and  the  obstetrician  likewise  have  been  given  a  new  light  on  many 
hitherto  poorly  understood  problems,  by  such  modern  contributions  as,  for 
example,  that  pertaining  to  the  menstrual  histology  of  the  endometrium,  or 
that  dealing  with  the  endocrine  relationships  of  the  ovary. 

It  would  seem,  therefore,  that  the  time  is  opportune  for  the  presentation 
of  a  volume  devoted  to  all  aspects  of  the  subject  of  menstruation,  both 
normal  and  abnormal.  So  far  as  I  know,  there  is  no  other  work  in  any 
language  with  exactly  this  scope.  This  statement,  I  believe,  will  apply  even 
to  the  rather  comprehensive  articles  in  some  of  the  German  handbooks. 
While  the  present  volume  is  monographic  in  character,  every  effort  has  been 
made  to  make  it  of  genuinely  practical  value,  to  general  practitioners  as  well 
as  to  specialists  in  gynecology  and  obstetrics.  The  surgical  treatment  of  the 
various  forms  of  pelvic  disease  which  may  be  associated  with  disturbances  of 
menstruation  has  not  been  considered,  for  this  would  mean  the  inclusion,  to 
all  intents  and  purposes,  of  a  treatise  on  operative  gynecology.  For  the  sake 
of  completeness,  however,  it  has  seemed  best  to  include  a  discussion  of  certain 
matters  of  merely  historic  interest. 

It  is  hoped  that  the  list  of  references  at  the  end  of  each  chapter  will  con- 
stitute a  good  working  bibliography  for  those  desirous  of  going  to  original 
sources.  These  lists  are  not  by  any  means  exhaustive,  but  the  references  have 
been  selected  as  the  most  worthwhile  of  the  many  hundreds  which  have  been 
consulted  in  the  preparation  of  this  work. 

To  Drs.  Howard  A.  Kelly  and  Curtis  F.  Burnam  I  am  greatly  indebted  for 
the  chapter  on  "  X-Ray  and  Radium  Treatment  of  Menstrual  Disorders."  To 
Dr.  Thomas  S.  Cullen,  professor  of  gynecology,  and  Dr.  J.  Whitridge  Williams, 
professor  of  obstetrics  at  Johns  Hopkins  Medical  School,  my  thanks  are  due 
for  their  helpful  criticisms.  Finally,  it  is  a  pleasure  to  acknowledge  the 
courtesy  and  cooperation  of  the  publishers,  D.  Appleton  and  Company. 

EMIL  NOVAK 


yu 


CONTENTS 

CHAPTER  PAGE 

I.     The  Superstition  and  Folk-I^re  of  Menstruation 1 

II.  Periodic  Sexual  Phenomena  in  the  Lower  Animals 10 

General  considerations,  10;  Importance  of  a  study  of  the  comparative  physiology 

of  menstruation,  10;  Earliest  manifestations  of  periodic  sex  activity,  10; 
Periodic  sexual  activity  in  the  lower  animals,  11;  "Heat"  or  estrus,  11; 
Anestrous  cycle,  12;  The  pro-estrum,  12;  The  period  of  estrus,  13;  The  metes- 
trum  and  di-estrum,  14;  The  di-estrous  cycle,  14;  The  estrous  cycle  in  various 
animals,  14;  Are  the  phenomena  of  estrus  and  menstruation  analogous?  16. 

III.  The  Source  of  the  Menstrual  Flow 19 

The  endometrium  the  source  of  the  menstrual  flow,  19;  The  role  of  the  cervix 
uteri,  19;  Do  the  fallopian  tubes  participate  in  menstruation?  20;  clinical 
evidence,  20;  histological  evidence,  21. 

IV.  Menstrual  Cyclic  Changes  in  the  Uterus 24 

Historical,  24;  Macroscopic  changes  in  the  uterus  at  the  time  of  menstruation,  25. 

the  endometrium   25 

Macroscopic  changes  associated  with  menstruation,  25 ;  Histological  changes  asso- 
ciated with  menstruation,  26;  Structure  of  normal  endometrium,  26;  Views 
as  to  menstrual  histology  of  the  endometrium,  26;  Changes  in  epithelium  dur- 
ing menstrual  cycle,  31 ;  Changes  in  uterine  glands  during  menstrual  cycle,  33 ; 
Stromal  changes  during  menstrual  cycle,  34;  Vascular  changes  of  menstruation, 
35 ;  Is  there  any  loss  of  uterine  mucosa  at  the  time  of  menstruation?  36. 

V.  Anatomic    Changes    in    Ovary   During    Menstrual    Cycle,    Including 

Life  Cycle  of  Corpus  Luteum 40 

Gross  anatomy  of  ovary,  40;  Macroscopic  changes  in  ovary  as  result  of  menstrua- 
tion, 40;  Histology  of  ovary,  41. 

the  follicies  of  the  ovary 42 

THE  corpus  luteum  43 

General,  43 ;  Older  views  as  to  corpus  luteum,  43 ;  Modern  conception  of  corpus 
luteum,  44;  Life  cycle  of  corpus  luteum,  45  ;  The  stage  of  proliferation,  45  ;  The 
stage  of  vascularization,  48;  The  stage  of  maturity,  50;  The  stage  of  retro- 
gression, 50;  Chronological  relation  of  corpus  luteum  cycle  to  menstrual  and 
endometrial  cycles,  52;  Comparison  of  corpus  luteum  of  menstruation  and 
corpus  luteum  of  pregnancy,  55. 

origin  of  lutein  cells 58 

Two  principal  theories,  58;  Origin  of  lutein  cells  In  lower  animals,  58;  Theory 
of  origin  from  connective  tissue,  58;  Theory  of  epithelial  origin  of  lutein  cells, 
58;  Present  status  of  question,  60. 

the  interstitial  cells  of  the  ovary 60 

General,  60;  Interstitial  cells  in  ovaries  of  lower  animals,  61;  Interstitial  cells  In 
human  ovary,  61 ;  Origin  of  interstitial  cells  from  walls  of  atretic  follicles,  63. 

VI.  Historical  Sketch  of  Older  Theories  of  Menstruation 67 

Introduction,  67;  The  earliest  theories  of  menstruation,  67;  The  theory  of  lunar 
influence,  67;  The  ferment  theory  —  the  "Fervor  uterlnus "  of  Democritu<; 
67;  The  plethora  theory  of  Galen,  67;  The  theory  of  Pfluger,  68;  The  "tubal 
nerve"  of  Tait,  68;  The  influence  of  the  vertical  position  in  causing  menstrua- 

ix 


X  CONTENTS. 

CHAPTER  PAOlE 

tion,  68;  Menstruation  as  a  jesult  of  the  sexual  appetite,  69;  "Women  men- 
struate because  they  do  not  conceive,"  69 ;  Menstruation  as  an  "  unnatural 
process,"  69;  Menstruation  as  a  true  secretory  process,  70;  The  theory  of  a 
menstrual  centre,  70;  Steps  leading  to  the  modern  conception  of  menstrua- 
tion, 70. 

VII.  The  Modern  Theory  of  Menstruation 73 

The  ovary  the  underlying  cause  of  menstruation,  73 ;  The  ovarian  influence 
exerted  through  blood  stream,  and  not  through  nerves,  73 ;  Which  constituent 
of  the  ovary  is  concerned  with  menstruation?  74;  The  corpus  luteum  theory 
of  Fraenkel,  74;  Other  modern  views  as  to  cause  of  menstruation,  74;  Theory 
of  Marshall,  74;  Theory  of  Theilhaber,  74;  Studies  of  Aschner,  75;  Investiga- 
tions of  Loeb,  75 ;  Theory  of  Halban,  75 ;  Recent  histological  confirmation  of 
corpus  luteum  theory,  76;  Injection  experiments,  77;  Conclusion  as  to  cause 
of  menstruation,  77;  Influence  of  endocrine  glands  other  than  ovary,  78; 
Vascular  and  vasomotor  factors  in  menstruation,  78;  A  local  factor  in  the 
endometrium,  78. 

VIII.  Clinical  Characteristics  of  Normal  Menstruation 81 

Introduction,  81;  Is  pain  a  symptom  of  normal  menstruation?  81;   Site  of  pain 

or  discomfort,  82;  Other  subjective  symptoms  of  menstruation,  83;  Statistics 
as  to  character  and  severity  of  subjective  symptoms,  83;  The  "libido 
sexualis"  and  menstruation,  84;  The  "menstrual  wave"  theory,  85;  Effect 
of  menstriiation  on  body  temperature,  86;  Effect  of  menstruation  on  blood 
pressure,  87;  Effect  of  menstruation  on  pulse  rate,  87;  Effect  of  menstruation 
on  muscle  power,  88;  Effect  of  menstruation  on  knee-jerk,  88;  Periodicity 
of  the  menstrual  flow,  88;  The  interval  between  menstrual  periods,  89; 
Duration  of  the  menstrual  period,  90;  Amount  of  blood  lost  at  menstruation, 
91 ;  Individual  differences,  91 ;  Methods  of  estimating  amount,  91 ;  Amount 
of  menstrual  discharge,  91;  Influence  of  menstruation  on  blood  picture,  92; 
Erythrocytes,  92;  Hemoglobin,  92;  Leukocytes,  93;  The  sugar  content  of  the 
blood,  94;  Objective  phenomena  of  menstruation,  94;  The  menstrual  discharge, 
94;  Chemical  composition  of  menstrual  blood,  94;  Non-coagulability  of 
menstrual  blood,  95 ;  Reasons  for  differences  of  opinion,  95 ;  Importance  of 
the  problem,  95 ;  The  role  of  the  alkaline  cervical  mucus,  95 ;  Possibility  of  a 
local  factor  in  the  endometrium,  96;  The  possible  influence  of  changes  in  coagu- 
lating time  of  body  blood  at  time  of  menstruation,  96;  The  absence  of  fibrin 
ferment  in  menstrual  blood,  96;  The  formation  of  antithrombin  by  the  endo- 
metrium, 96 ;  The  biological  role  of  the  endometrium  an  important  factor,  97. 

IX.  Puberty  and  the  Onset  of  Menstruation 100 

General  considerations,   100;   General  body  changes   at  puberty,  100;   Changes  in 

reproductive  organs,  100;  Psychic  changes,  101;  Physiological  changes,  101; 
Menstruation  only  one  of  the  manifestations  of  puberty,  101 ;  Age  at  which 
menstruation  appears,  102;  Factors  influencing  age  of  onset  of  menstruation, 
104;  Cause  of  puberty,  105. 

X.  The  Hygiene  of  Puberty 108 

The  role  of  the  mother,  108;  Instruction  in  sex  hygiene,  108;  School  life,  109; 
Working  conditions,  109;  Recreation  and  rest,  110;  Clothing,  110;  Bathing, 
111;  Diet,  111;  Care  of  the  bowels,  112;  Other  hygienic  measures  of  im- 
portance, 112. 

XI.  Precocious  Menstruation 113 

What  constitutes  precocious  menstruation?  113;  Early  manifestations  of  premature 
development,  113;  Frequency,  113;  Age  at  which  precocious  menstruation  may 
be  observed,  114;  Types  of  precocious  menstruation,  115;  Clinical  manifesta- 
tions, 115;  Subsequent  history  of  patients  with  precocious  menstruation,  116; 
Psychic  development,  117;  Pregnancy  in  cases  of  precocious  menstruation, 
117;  Cause  of  precocious  menstruation,  117;  Diagnosis  of  precocious  menstrua- 
tion, 118;  Treatment  of  precocious  menstruation,  119. 

XTT.    Non-Menstrual  Genital  Hemorrhage  in  the  New  Born 121 

Differentiation  from  precocious  menstruation,  121  ;  Frequency,  121  ;  Time  of  occur- 
rence of  bleeding,  121;  Duration  of  bleeding,  122;  Amount  and  character  of 
bleeding,  122;  Accompanying  symptoms,  122;  Prognosis,  122;  Etiology,  122; 
Treatment,  123. 


CONTENTS.  xi 

CHAPTER  PAGE 

XIII.  The  Menopause 125 

Definition,  125;  Historical,  125;  The  age  at  which  the  menopause  occurs,  126; 
Factors  influencing  the  age  of  the  menopause,  127;  Age  at  which  menstruation 
begins,  127;  Maternity,  127;  Climate,  127;  Race,  128;  Heredity,  128;  Social 
condition,  128;  Obesity,  128;  Wasting  diseases,  128;  Pelvic  disease,  128;  Early 
menopause,  128;  Delayed  menopause,  129;  The  Surgical  menopause,  129;  Dura- 
tion of  menopause,  130;  Symptoms  of  the  menopause,  130;  General  course, 
130;  Cessation  of  menstruation,  131;  Vasomotor  symptoms,  132;  Psychic 
symptoms,  133;  Nervous  symptoms,  133;  Other  symptoms,  134;  Factors  in- 
fluencing the  severity  of  the  menopause,  134;  Anatomic  changes  of  the  meno- 
pause, 135;  External  genitalia,  135;  Internal  genitalia,  136;  Other  changes, 
137;  Diagnosis,  137. 

treatment  of  menopausal  disturbances , .      139 

General  measures,  139;  Treatment  by  drugs,  139;  Hemorrhage,  139;  Nervous 
symptoms,  140;  Vasomotor  symptoms,  140;  Local  symptoms,  141;  Organo- 
therapy, 142. 

XIV.  The  Hygiene  of  the  Menopause 143 

General  measures,  143 ;  Significance  of  climacteric  hemorrhage,  143 ;  The  education 

of  women  as  to  the  dangers  of  cancer,  143;  The  responsibility  of  the  phy- 
sician, 144. 

XV.  Psychopathies  of  the  Menopause 146 

Incidence,  146;  Influence  of  the  marital  state,  146;  Age  of  patients,  146;  Influence 

of  heredity,  147;  Correlated  causes,  147;  Previous  attacks,  147;  Types  of 
mental  disorder,  147;  Illustrative  cases,  148;  Prognosis,  148. 

XVI.  Relation  of  Menstruation  and  Ovulation 150 

Historical,  150;  Relation  of  estrus  and  ovulation  in  lower  animals,  150;   Clinical 

observations  on  relation  of  menstruation  and  ovulaton,  152;  General  con- 
siderations, 152 ;  Ovulation  before  puberty,  152 ;  Ovulation  during  "  dodging 
period "  of  puberty  and  menopause,  152 ;  Ovulation  after  menooause,  153 ; 
Ovulation  during  pregnancy,  153 ;  Ovulation  during  lactation,  153 ;  Ovulation 
during  pathological  amenorrhea,  153 ;  Evidence  from  operative  and  postmortem 
findings,  154;  Summary  of  clinical  evidence,  155;  Histological  studies  on 
relation  of  ovulation  and  menstruation,  155 ;  General,  155 ;  Evidence  from 
embryological  studies,  155;  Histological  studies  of  ovary,  158;  Summary  of 
histological  evidence,  159. 

XVII.  Relation  of  Menstruation  to  Lactation 162 

Is  amenorrhea  the  rule  during  lactation?  162;  Statistics  bearing  on  the  dis- 
cussion, 162 ;  Reasons  for  the  discrepancy  in  statistics,  163 ;  Cause  of  amenor- 
rhea during  lactation,  163;  Ovulation  during  lactation,  164;  Influence  of 
menstruation  on  breast  milk,  164. 

XVIII.  Amenorrhea  .  .  „ 167 

Definition  and  varieties,  167;   Primary  amenorrhea,  167;   Secondary  amenorrhea, 

167;  Distinction  between  amenorrhea,  retention  of  menses,  and  suppression 
of  menses,  167. 

causes  of  amenorrhea 168 

Classification  of  causes,  168;  Local  causes,  168;  Congenital  absence  or  malformation 
of  reproductive  organs,  168;  Acquired  pathological  conditions  of  pelvic  organs, 
169;  General  causes,  170;  Physiological  amenorrhea,  170;  Functional  amenor- 
rhea, 171;  Amenorrhea  due  to  acute  infectious  diseases,  172;  Amenorrhea 
due  to  constitutional  diseases,  172;  Amenorrhea  due  to  miental  and  nervous 
disorders,  173;  Amenorrhea  due  to  ductless  gland  disorders,  173;  Significance 
of  amenorrhea  as  a  symptom,  174;  Is  amenorrhea  detrimental  to  the  health? 
174;  Symptoms  which  may  be  associated  with  amenorrhea,  175;  Diagnosis  of 
cause,  176. 

treatment  of  amenorrhea 177 

Treatment  of  underlying  cause,  177;  General  measures,  177;  Medical  treatment, 
178;  Iron  in  the  treatment  of  amenorrhea,  178;  Arsenic,  179;  Questionable 
value  of  emmenagogues,  179;  Organotheraphy  of  amenorrhea,  181. 


xii  CONTENTS. 

CHAPTER  PAGE 

XIX.  Gynatresia  and  Retention  of  the  Menstrual  Discharge 183 

General  conditions,  183;  Types  of  gynatresia,  183;  Causes  of  primary  or  con- 
genital gynatresia,  183;  The  Nagel-Veit  theory,  183;  Imperforate  hymen,  184; 
Other  forms  of  obstruction,  184;  Secondary  or  acquired  gynatresia,  184; 
Puerperal  infection  or  lacerations,  184;  Infectious  diseases,  185;  Trauma,  185 
Senile  atresia,  185 ;  Mechanical  occlusions  from  within  or  without  the  genital 
canal,  186;  Symptoms  of  gynatresia,  187;  Chemical  composition  of  retained 
menstrual  discharge,  187;  Cause  of  hematosalpinx  in  cases  of  gynatresia,  187; 
Diagnosis  of  gynatresia,  187;  Prognosis,  188;  Treatment,  188. 

XX.  Dysmenorrhea 190 

General  considerations,  190;  Types  of  dysmenorrhea,  191;  Frequency  of  dysmenor- 
rhea, 191. 

CAUSES    OF    PRIMARY    DYSMENORRHEA 191 

General  considerations,  191;  Mechanical  obstruction  of  uterine  canal,  192;  relation 
of  anteflexion  to  dysmenorrhea,  193;  Hypoplasia  of  reproductive  organs,  193; 
Role  of  neuroses  in  causation  of  dysmenorrhea,  196;  Hysterical  dysmenorrhea, 
197;  Dysmenorrhea  of  neurasthenic  origin,  198;  Neuralgic  dysmenorrhea,  199. 

CAUSES    OF    SECONDARY    DYSMENORRHEA 199 

General  considerations,  199 ;  Constitutional  disease  as  a  factor,  199 ;  Chlorosis  and 
other  forms  of  anemia,  199;  Tuberculosis,  200;  Other  constitutional  disorders, 
200;  Dysmenorrhea  due  to  local  pelvic  disease,  200;  Retrodisplacement  of 
uterus,  201 ;  Inflammatory  disease  of  pelvic  organs,  201 ;  Myomata  of  uterus, 
202;  Other  forms  of  pelvic  disease,  202, 

CLINICAL  CHARACTERISTICS  OF  DYSMENORRHEA 202 

Clinical  types,  202 ;  Spasmodic  dysmenorrhea,  202 ;  Congestive  dysmenorrhea,  203. 

TREATMENT  OF  DYSMENORRHEA 203 

General  considerations,  203;  Treatment  during  attack,  203;  General  measures.  203; 
Drugs,  203 ;  The  atropin  treatment  of  spasmodic  dysmenorrhea,  205 ;  Treat- 
ment by  benzyl  benzoate,  208;  The  mammary  treatment  of  dysmenorrhea, 
208;  Measures  for  permanent  relief  of  dysmenorrhea,  208;  Measures  for  per- 
manent cure  of  primary  dysmenorrhea,  209;  The  physiological  cure,  209; 
Importance  of  accurate  diagnosis,  209;  Dilation  of  cervix  by  rapid  method, 
209;  Continuous  dilation  by  stem  pessaries,  210;  Plastic  operations  on  cervix, 
211;  The  permanent  cure  of  secondary  dysmenorrhea,  211. 

MEMBRANOUS    DYSMENORRHEA     211 

General  considerations,  211;  Clinical  characteristics,  212;  Etiology,  212;  Mechanism 
of  detachment  of  membrane,  213;  Structure  of  menstrual  membranes,  214; 
Macroscopic  appearance,  214;  Microscopic  structure,  215;  Diagnosis,  215; 
Prognosis,  217;  Treatment,  217 

NASAL  DYSMENORRHEA 218 

General  considerations,  218;  The  "genital  spots"  in  the  nose,  218;  Theories  as  to 
nature  of  relation  between  generative  organs  and  nose,  218;  The  cocain  test 
of  nasal  dysmenorrhea,  219;  Permanent  cure  of  nasal  dysmenorrhea,  219; 
Need  of  caution  in  estimating  results  of  treatment,  220;  Method  of  treat- 
ment, 220. 

XXI.  INTERMENSTRUAL    PAIN     224 

Definition,  224;  Frequency,  224;  Time  of  occurrence  of  attacks,  224;  Character  of 
pain,  225;  Location  of  pain,  225;  Duration  of  pain,  225;  Associated  vaginal 
discharge,  225;  Age  of  patients,  225;  Marital  and  obstetrical  histories  of 
patients,  226;  Character  of  menstruation,  226;  Associated  pelvic  lesions,  226; 
Etiology,  226;  Treatment,  227. 

XXTT.    Uterine  Hemorrhage  229 

General  considerations,  229 ;  Relative  importance  of  anatomic  and  physiologic  fac- 
tors, 229;  Classification  of  causes  of  uterine  bleeding,  230;  Constitutional 
causes  of  uterine  hemorrhage,  230;  Acute  infectious  diseases,  230;  Constitutional 
diseases,   230;    Organic    diseases,    231;    Chronic    intoxications,   231;    Anatomic 


CONTENTS.  xiii 

CHAPTER  PAGE 

causes  of  uterine  hemorrhage,  231 ;  Polypi,  231 ;  Cervical  polypi,  231 ;  Corporeal 
polypi,  232;  Cervical  ectropion  and  erosion,  232;  Retention  of  gestation 
products,  2Z2\  Clinical  considerations,  232;  Histological  findings,  233;  Endome- 
tritis, 234;  Hyperplasia  of  the  endometrium,  234;  Muscular  insufficiency  of 
.the  uterus,  236;  Arteriosclerosis  of  the  uterine  vessels,  238;  Carcinoma  of  the 
uterus,  239;  Sarcoma  of  the  uterus,  239;  Hydatidiform  mole,  239;  Chorio- 
epithelioma,  239;  Uterine  myoma  and  adenomyoma,  240;  Ectopic  pregnancy, 
242;  Tuberculosis  of  the  generative  organs,  242;  Inflammatory  disease  of  the 
adnexa,  243;  Tumors  of  the  ovary,  243;  Tumors  of  the  tube,  244;  Internal 
secretory  causes  of  uterine  hemorrhage,  244;  Hyperoophorism,  hypergonadism, 
244;  Disorders  of  other  endocrin  glands  than  ovary,  245;  Local  factor  in 
endometrium,  246;  Functional  uterine  bleeding,  246;  The  role  of  the  endocrine 
glands,  247;  The  nervous  causes  of  uterine  hemorrhage,  251;  General  con- 
siderations, 251;  Vasomotor  disturbance  due  to  nervous  or  psychic  influence, 
251;  Treatment  of  uterine  bleeding,  252;  Treatment  of  cause,  252;  Constitu- 
tional treatment,  253 ;  Physical  measures.  253 ;  Rest  in  bed,  253 ;  Cold  applica- 
tions to  abdomen,  253;  Hot  vaginal  douches,  253;  Vaginal  tampons,  254; 
Treatment  by  drugs,  254;  Ergot,  254;  Hydrastis,  255;  Cotarnine  phthalate,  255; 
Other  drugs  for  internal  administration,  255;  Intra-uterine  applications  of 
drugs,  255 ;  Injections  of  blood  and  serum,  256;  Treatment  of  functional  uterine 
hemorrhage,  256. 

XXIII.  Vicarious  Menstruation 261 

Definition  and  varieties,  261 ;   Incidence,  261 ;    Sources   of  hemorrhage,  261 ;   The 

nasal  mucous  membrane,  261;  The  stomach,  262;  The  intestinal  canal,  262; 
The  lungs,  262;  The  mammary  glands,  263;  The  skin,  263;  The  lips,  264; 
The  eye  and  eyelids,  264;  Nevi,  264;  The  kidneys,  264;  Old  cicatrices,  264; 
Abdominal  fistulae,  265 ;  The  umbilicus,  265 ;  Other  seats  of  vicarious  men- 
struation, 265 ;  Menstrual  history  in  cases  of  vicarious  menstruation,  265 ; 
Vicarious  menstruation  during  pregnancy,  265;  Cause  of  vicarious  menstru- 
ation, 265 ;  Diagnosis,  266  •  Treatment   267. 

XXIV.  Menstruation  and  the  Endocrine  Glands 269 

Introductory,  269 ;  Characteristics  of  endocrine  bodies,  269 ;  The  principal  endocrine 
structures,  and  their  importance  to  the  body  economy,  269. 

the  ovary  270 

The  ovary  as  an  endocrine  gland,  270;  The  part  played  by  the  ovary  at  puberty  and 
at  the  menopause,  270;  Castration  in  early  life,  270;  The  surgical  menopause 
and  its  manifestations,  271;  Cause  of  symptoms  of  artificial  menopause,  272; 
Transplantation  of  the  ovaries,  272;  General  results,  272;  Operative  technic  of 
autotransplantation  of  ovarian  tissue,  273;  Present  status  of  ovarian  trans- 
plantation, 273;  Menstruation  after  removal  of  the  ovaries,  274;  "  Pseudo 
menstruation,"  274;  Menstruation  after  apparently  complete  removal  of 
ovaries,  274;  Theories  of  persistence  of  menstruation  after  oophorectomy,  274. 

THE  THYROID  GLAND 276 

Evidences  of  relation  betw^een  thyroid  gland  and  gonads,  276;  Thyroid  disease  as  a 
result  of  pelvic  lesions,  276;  Menstrual  disorders  accompanying  thyroid  dis- 
ease, 276. 

THE  PITUITARY  BODY 217 

General,  277:  Adiposogenital  dystrophy  (Frohlich's  syndrome),  277;  Influence 
of  pituitary  on  body  growth,  278;  Pituitary  hypertrophy  in  pregnancy,  278; 
Pituitary  hypertrophy  after  castration,  278. 

THE  suprarenal  BODIES 279 

Difference  in  function  between  cortex  and  medulla,  279;  Indications  of  relation 
between  function  of  suprarenals  and  gonads,  279 ;  Effects  of  suprarenal  tumors 
on  reproductive  system,  279;  Changes  in  sexual  apparatus  associated  with 
suprarenal  hypertrophv,  without  tumor,  280;  Retarded  sexual  development 
associated  with  suprarenal  hypoplasia,  280. 


xiv  CONTENTS. 

CHAPTER  PAGE 

THE  PINEAL   BODY    280 

General,  280;  The  so-called  pineal  syndrome,  280;  Feeding  experiments,  281; 
Results  of  extirpation,  281. 

THE    THYMUS     GLAND 281 

THE     MAMMARY     GLAND 282 

THE    PANCREAS     283 

XXV.    REaPROCAL  Relations  of  Menstruation  and  Various  Diseases 288 

Introduction,  288. 

TUBERCULOSIS   AND    MENSTRUATION 288 

General  considerations,  288;  The  influence  of  tuberculosis  upon  menstruation, 
288;  Amenorrhea  more  common  than  menorrhagia,  288;  Influence  of  the  age 
of  the  patient,  289;  Influence  of  the  stage  of  the  disease,  289;  Menstrual  dis- 
turbance not  usually  dependent  on  local  lesions  in  pelvis,  289;  Explanation  of 
amenorrhea  in  tuberculosis,  290;  Practical  importance  of  amenorrhea  in  tuber- 
culosis, 290;  Menorrhagia  in  tuberculosis,  290;  Dysmenorrhea  in  the  tuberculous, 
291;  Influence  of  menstruation  upon  tuberculosis,  292;  General  considerations, 
292;  Historical,  292;  Premenstrual  fever  in  consumptives,  292;  Postmenstrual 
fever,  293 ;  Other  types  of  fever  in  consumption,  293 ;  Influence  of  menstrua- 
tion upon  subjective  symptoms  of  the  disease,  293. 

TYPHOID    FEVER    AND    MENSTRUATION 294 

Eflfect  of  typhoid  on  menstruation,  294;  General  considerations,  294;  Menstruation 
usually  diminished  or  absent,  294;  Significance  of  uterine  bleeding  in  the 
hemorrhagic  type  of  typhoid,  294;  Variations  in  effect  of  typhoid  on  men- 
struation, 294;  Menstruation  during  convalescence,  295;  Effect  of  menstruation 
upon  typhoid  fever,  295 ;  General  considerations,  295 ;  Importance  of  relation 
of  menstrual  date  to  time  of  onset  of  disease,  295 ;  Effect  of  menstruation  on 
fever,  296;  Influence  of  menstruation  on  treatment  of  typhoid,  296. 

PNEUMONIA  AND  MENSTRUATION 297 

Eft'ect  of  pneumonia  on  menstruation,  297;  Occurrence  of  menstruation,  297. 

OTHER   INFECTIOUS   DISEASES    AND    MENSTRUATION 297 

Syphilis,  297;  Influenza,  298;  Acute  exanthematous  diseases,  298;  Other  infectious 
diseases,  298. 

DISEASES  OF  THE  BLOOD  IN  RELATION  TO  MENSTRUATION 298 

Chlorosis,  298;  Characteristics  of  the  disease,  298;  Effect  of  chlorosis  on  men- 
struation, 299;  Amenorrhea  the  common  menstrual  symptom  in  chlorosis, 
299;  Menorrhagia  occasionally  observed,  300;  Dysmenorrhea  a  frequent 
symptom.,  300;  Treatment  of  menstrual  disorders  of  chlorosis,  300;  Effect 
of  menstruation  on  chlorosis,  300;  Harmfulness  of  emmenagogues,  300;  Per- 
nicious anemia,  300;  Leukemia,  300;  Hemophilia,  301. 

DISEASES  OF  THE  THYROID  GLAND  IN  RELATION  TO  MENSTRUATION 301 

Graves'  disease  and  menstruation,  301 ;  Myxedema  and  menstruation,  302. 

DIABETES    AND    MENSTRUATION    302 

GASTRO-INTESTINAL   DISEASES    AND    MENSTRUATION 303 

Effect    of    menstruation    on  secretory    and    motor    functions    of    stomach,    303; 

Stomach    disorders    and  menstruation,    303;    Liver    diseases,    303;    Menstrual 

hyperemia   of   the   liver  and   mensitrual   jaundice    (icterus    menstrualis),   303; 
Cholelithiasis,  304. 

JOINT  DISEASES  AND  MENSTRTTATION , ,  ,         304 

Acute  articular  rheumatism  and  "menstrual  arthitis,"  304, 


CONTENTS.  XV 

CHAPTER  PAGE 

NERVOUS  AND  MENTAL  DISEASES  AS  RELATED  TO   MENSTRUATION 305 

Epilepsy,  305;  Hysteria,  306;  Insanity,  307;  Chronic  intoxication,  307. 

THE     MENSTRUAL    DERMATOSES 307 

Occurrence  of  the  menstrual  dermatoses,  307;  Herpes,  308;  Urticaria,  308;  Angio- 
neurotic edema,  308;  Erythema,  308;  Erysipelas,  309;  Acne,  309;  Ecchymoses, 
309;  Erythema  nodosum,  309;  Skin  pigmentation,  310. 

XXVI.  The  Organotherapy  of  Menstrual  Disorders 314 

Introductory,  314;  Organ  extracts  which  may  be  used  in  the  treatment  of  menstrual 

disorders,  314;  General  considerations,  314;  Thyroid  extract,  315;  Pituitary 
extract,  315;  Extract  of  ovary  or  corpus  luteum,  316;  Types  of  menstrual  dis- 
order in  which  organotherapy  is  indicated,  317;  Amenorrhea,  317;  Menstrual 
and  development  disorders  of  puberty,  317;  Functional  amenorrhea  of  later 
life,  318;  Uterine  hemorrhage,  321;  Vasomotor  symptoms  of  menopause,  323; 
Dysmenorrhea,  324. 

XXVII.  The  Treatment  of  Menstrual  Disorders  by  Radium  and  X-Ray.  .      ZZJ 
Introduction,  327;  History,  327;  Literature  of  the  subject,  328;  Anatomical  changes 

in  uterus  and  ovaries  after  radiation,  329;  The  Ray  menopause,  330;  The  tech- 
nic  of  radiation,  330;  Classification  of  dysmenorrhea  from  the  standpoint  of 
ray  therapy,  331 ;  Cases  with  abnormality  of  the  menstrual  flow^,  331 ;  Cases 
characterized  by  painful  menstruation,  2i2i2\  Cases  with  marked  nervous  or 
psvchical  disturbances,  principally  or  solely  present  during  menstrual  periods, 
333. 


ILLUSTRATIONS 

FIGURE  PAGE 

1.  Normal  cervical  gland  19 

2.  Normal  endometrium  20 

3.  The  endometrium  in  the  postmenstrual  stage 27 

4.  The  endometrium  in  the  interval  stage 28 

5.  The  endometrium  in  the  premenstrual  phase  29 

6.  Endometrium  on  second  day  of  menstruation  30 

7.  The  characteristic  changes  in  the  uterine  epithelium,  glands,  and  stroma 

at  the  various  phases  of  the  menstrual  cycle 32 

8.  Developing  follicle   41 

9.  Developing  follicle ;  later  stage  than  Fig.  8 42 

10.  Follicle  approaching  maturity  43 

11.  Section  through  wall  of  mature  follicle 45 

12.  Portion  of  wall  of  early  "corpus  luteum,  removed  on  tenth  day  of  cycle..  46 

13.  High  power  picture  of  corpus  luteum  shown  in  Fig.  12 47 

14.  Wall  of  early  corpus  luteum,  slightly  more  advanced  than  that  shown 

in  Fig.  12 .••■.•••••; "^ 

15.  Wall  of  corpus  luteum  in  stage  of  early  vascularization,  sixteenth  day. .  49 

16.  Wall  of  mature  corpus  luteum,  twenty-seventh  day 50 

17.  Contrast  between  lutein  and  paralutein  cells,  near  top  of  septum  shown 

at  p  in  Fig.  16 ^ • . .  51 

18.  A  transverse  section  of  the  ovary,  about  three  times  the  normal  size, 

showing  a  large,  mature  corpus  luteum 52 

19.  Corpus  luteum,  showing  beginning  of  retrogression 53 

20.  A  corpus  albicans 54 

21.  Corpus  luteum  in  a  case  of  early  pregnancy 56 

22.  Sections  of  ovary  of  infant  2  days  old 61 

23.  Corner  of  atretic  follicle 62 

24.  Cystic  atretic  follicle  undergoing  obliteration  63 

25.  Precocious  development  in  a  girl  of  six  116 

26.  Senile  endometrium,  from  a  patient  aged  49  years 136 

27.  Senile  changes  as  seen  on  transverse  section  of  ovary 138 

28.  Entire  albsence  of  the  vagina,  with  indication  of  double  hymen 170 

29.  Acquired  atresia  of  the  vagina  or  hymen  185 

30.  An  elongate  infantile  ovary  with  puerile  type  of  uterine  body 194 

31-  The  fetal  type  of  uterine  hypoplasia,  as  compared  with  the  normally 

developed  uterus   196 

32.  Types  of  infantile  uteri,  in  comparison  with  the  normal  197 

33.  Types   of   subpubescent  uteri,   showing  only  slight  differences  in   size 

from  normal  uteri 197 

34.  Cast  of  uterus  in  a  case  of  membranous  dysmenorrhea 214 

35.  Structure  of  uterine  cast  of  the  decidual  type,  associated  with  mem- 

branous  dysmenorrhea    216 

36.  Curettings  from  a  case  of  incomplete  abortion 234* 

37.  Hyperplasia  of  the  endometrium  237 

38.  Radiograph  of  the  arterial  supply  of  the  entire  uterus 240 

39.  Arterial  supply  of  the  uterine  tissues 241 

40.  Dystrophia  adiposogenitalis  277 


xvii 


MENSTRUATION 
AND  ITS  DISORDERS 

CHAPTER   I 

THE  SUPERSTITION  AND   FOLKLORE   OF  MENSTRUATION 

From  the  very  earliest  times  the  phenomenon  of  menstruation  has  been 
the  subject  of  much  speculation  and  study.  The  older  ideas  as  to  the  nature 
of  the  menstrual  process  represent  a  curious  blending  of  speculation  and 
superstition,  with  very  little  foundation  of  real  fact.  The  element  of  mys- 
tery in  the  phenomenon  seems  to  have  inhibited  intelligent  efforts  to  study 
it.  Apparently  there  v^as  a  general  acceptance  of  the  depressing  dictum  later 
enunciated  by  Colombat,  that  "the  mystery  of  menstruation  will  be  forever 
covered  with  a  veil  which  cannot  be  perfectly  removed."  It  is  gratifying 
to  note  that  the  scientific  methods  of  our  own  generation  have  already 
yielded  splendid  additions  to  our  knowledge  of  this  problem.  Much  has 
been  done  to  dispel  the  numberless  superstitions  which  formerly  befogged 
the  subject  in  the  minds  of  both  the  laity  and  the  profession. 

Many  of  these  old  beliefs  concerning  menstruation  are  of  interest,  and 
I  have  thought  it  might  be  well  worth  while  gathering  some  of  them 
together  in  a  chapter  which  would  fittingly  introduce  the  consideration  of 
menstruation  from  a  modern  viewpoint. 

Even  before  the  time  of  Hippocrates,  menstruation  seems  to  have  been 
looked  upon  as  a  cleansing  process  —  a  periodic  purging  of  the  blood  from 
filth  and  impurity.  The  very  name  given  by  the  Greeks  to  the  process  of 
menstruation  (Kadapais,  catharsis)  is  indicative  of  this  belief  in  the  cleansing 
function  of  the  menstrual  flow.  It  is  still  the  popular  conception  among 
the  laity,  and  perhaps  among  a  certain  proportion  of  the  profession.  The 
disagreeable  odor  of  menstrual  blood  may  be  in  part  responsible  for  this 
belief. 

Pliny  spoke  of  the  menstrual  blood  as  being  "  a  fatal  poison,  corrupting 
and  decomposing  urine,  depriving  seeds  of  their  fecundity,  destroying 
insects,  blasting  garden  flowers  and  grasses,  causing  fruits  to  fall  from 
branches,  dulling  razors,  etc."  (Lib.  VII,  Cap.  15.)  Pliny  also  states  that 
the  dog  which  licks  menstrual  blood  becomes  mad,  although,  curiously 
enough,  as  we  gball  see,  menstrual  blood  was  later  recommended  as  a  cure 

I 


2  MENSTRUATION  AND  ITS  DISORDERS 

for  the  bite  of  a  mad  dog.  He  says,  further,  that  "  If  a  woman  strips 
herself  while  she  is  menstruating  and  walks  round  a  field  of  wheat,  the 
caterpillars,  worms,  beetles,  and  other  vermin  will  fall  from  the  ears  of 
corn,  Metrodorus,  of  Scepsos,  tells  us  that  the  discovery  was  first  made 
in  Cappadocia,  and  that,  in  consequence  of  such  multitudes  of  cantharides 
being  found  to  breed  there,  it  is  the  practice  for  women  to  walk  through  the 
middle  of  the  fields  with  their  garments  tucked  above  their  thighs.  In 
other  places,  again,  it  is  the  usage  for  women  to  go  barefoot,  with  their  hair 
dishevelled  and  the  girdle  loose;  due  precautions  must  be  taken,  however, 
that  this  is  not  done  at  sunrise,  for,  if  so,  the  crop  would  wither  and  dry 
up". /'Astruc  is  another  author  who  speaks  of  the  ancient  belief  that  the 
menstrual  discharges  were  so  venomous  that  "  they  withered  and  dried  up 
the  flowers,  marred  liquors,  tarnished  looking  glasses,  with  several  other 
astonishing  effects." 

Bees,  according  to  Pliny,  are  said  to  have  an  especial  aversion  to  a  thief 
and  to  a  menstruating  woman,  a  glance  of  such  a  woman's  eyes  being 
sufficient  to  kill  a  swarm  of  bees.  Horses  are  also  susceptible  to  this  malign 
influence.  "A  mare  big  with  foal,  if  touched  by  a  woman  in  this  state,  will 
be  sure  to  miscarry ;  nay,  even  more  than  this,  at  the  very  sight  of  a  woman, 
though  seen  even  at  a  distance,  should  she  happen  to  be  menstruating  for 
the  first  time  after  the  loss  of  her  virginity,  or  for  the  first  time  while  in  a 
state  of  virginity.  So  pernicious  are  the  properties  of  the  menstrual  dis- 
charge that  women  themselves,  the  source  from  which  it  is  derived,  are 
far  from  being  proof  against  its  effects.  A  pregnant  woman,  for  instance, 
if  touched  with  it,  or  if  indeed  she  so  much  as  steps  over  it,  will  be  liable  to 
miscarry"  ( Pliny). ^ 

Such  beliefs  are  responsible  for  the  abhorrence  in  which  the  menstruating 
woman  was  universally  held.  This  is  perhaps  best  epitomized  in  the  Mosaic 
law :  "  If  a  man  shall  lie  with  a  woman  having  her  sickness,  and  shall 
uncover  her  nakedness,  he  hath  discovered  her  fountain,  and  she  hath 
uncovered  the  fountain  of  her  blood,  and  both  of  them  shall  be  cut  off  from 
among  their  people  "  (Lev.  XX,  i8).  The  menstruating  woman  was  held 
to  be  unclean  for  seven  days,  at  the  end  of  which  time  she  sacrificed  turtle- 
doves as  a  burnt  offering. 

Coitus  at  such  a  period  was  looked  upon  as  a  very  grave  offense.  In 
ancient  Persia,  the  persons  guilty  of  such  an  act  were  devoted  to  the  fires 
of  hell  until  the  day  of  Judgment.  The  Zend  Avesta  is  full  of  regulations 
tending  to  isolate  "  unclean  "  women,  while  metrorrhagia  is  condemned  as 
a  crime  punishable  by  one  hundred  strokes  of  the  lash.  It  is  said  that  even 
among  modern  Greeks,  menstruating  women  are  denied  communion  in  the 
church  and  are  forbidden  to  kiss  the  church  pictures  (Ploss).  The  Bible 
makes  frequent  mention  of  menstruation,  though  usually  in  paraphrase. 
The  word  "  menstruous  "  is  employed  three  times,  and  always  in  the  sense 
of  unclean  and  repellant,  as  when  Jeremiah  says  "  Jerusalem  is  as  a 
menstruous  woman  among  them." 


THE  SUPERSTITION  AND  FOLKLORE  OF  MENSTRUATION  3 

/  History  tells  us,  furthermore,  that  by  a  decree  of  the  Council  of  Nice, 
women  were  forbidden  to  enter  church  while  menstruating,  so  that  evidently 
it  was  not  only  the  ignorant  who  entertained  the  peculiar  notions  of  the 
uncleanness  of  women  during  menstruation.  It  is  even  said  that  certain 
surgeons  would  not  allow  menstruating  nurses  to  assist  in  operations. 

German  peasants,  according  to  Ploss,  believe  that  a  menstruating  woman 
"entering  the  cellar  turns  the  wine  of  the  Fatherland  sour;  and  that  if  she 
crosses  a  field,  she  spoils  the  growth  of  the  vegetation.  /The  humbler  class 
of  Jewesses  are  accustomed  to  signal  their  menstrual  period  to  their  hus- 
bands by  a  curious  ritual  observance ;  they  tie  bows  of  blue  ribbons  to  their 
beds  or  chairs.  Similarly,  negresses  in  certain  parts  of  Africa  wear  a  scarf 
of  glaring  color  folded  three  corner  wise  over  the  bosom  during  the  menses. 
Along  the  Congo  River  the  "  house  of  blood,"  a  hut  daubed  with  red,  is  used 
for  the  purpose  of  segregating  the  tribeswomen  of  each  village  when  in  this 
condition  (Knott). 

The  negresses  of  Surinam  must  also,  according  to  Ploss,  live  apart  from 
their  tribes  during  the  menstrual  periods.  Moreover,  when  anyone  ap- 
proaches them,  they  must  call  out  "  Mi  kay !  Mi  kay !  "  —  "I  am  unclean ! 
I  am  unclean !  "  The  same  author  also,  in  his  monumental  work,  "  Das 
Weib,"  gives  innumerable  other  examples  of  this  almost  universal  belief 
among  savage  and  barbarous  peoples.  A  few  other  examples  may  be  cited 
of  this  remarkable  taboo  put  upon  the  menstruating  woman. 

In  Angola  the  women  are  obliged  to  wear  a  bandage  about  the  head 
during  the  period  of  menstruation.  If  bleeding  persists  beyond  this 
time,  the  woman  is  considered  to  be  under  the  influence  of  evil  spirits,  and 
is  punished  with  one  hundred  lashes  of  the  whip. 

Certain  tribes  believe  that  the  process  is  dangerous,  not  only  to  others, 
but  to  the  menstruating  woman  herself,  and  so  they  enforce  a  strict  dietetic 
regime  at  that  time. 

Among  the  Tinneh  Indians,  according  to  Frazer,  it  Is  dangerous  for  a 
m-enstruating  girl  to  touch  her  head  with  her  hand.  If  she  finds  it  neces- 
sary to  scratch  her  head,  this  must  be  done  with  a  stick.  Among  some  tribes 
she  is  not  even  allowed  to  feed  herself,  and  among  others,  she  is  obliged  to 
wear  hanging  from  her  forehead  a  fringe  made  of  shells  or  bones.  The 
purpose  of  this  is  to  cover  her  eyes,  as  she  is  especially  susceptible  to  the 
influence  of  malicious  sorcerers  at  this  time  (Crawfurd),  Among  certain 
races,  menstruating  women  are  forbidden  to  eat  anything  that  bleeds, 
as  this  would  increase  the  severity  of  the  flux  In  the  transgressor.  Among 
the  Persians,  the  women  are  likewise  segregated  at  the  time  of  menstruation. 
The  usual  period  of  isolation  is  four  days ;  the  maximum  is  nine  days. 

The  Indian  women  of  the  Orinoco  country  in  South  America  are  obliged 
to  fast  during  each  menstrual  period,  while  among  the  North  American 
tribes,  the  squaws  are  sequestered  in  separate  huts  during  menstruation. 
According  to  Colombat,  the  Illinois  Indians  punished  with  death  any  of  their 
squaws  who  failed  to  give  notice  that  they  >vere  affected  by  the  periodic 


4  MENSTRUATION  AND  ITS  DISORDERS 

discharge.  In  the  same  way  Crawfurd  mentions  the  case  of  an  AustraHan 
black  who  killed  his  wife  because  she  had  lain  on  his  blanket  while  she  was 
menstruating.     He  himself  is  said  to  have  died  of  terror  within  a  fortnight. 

Among  some  of  the  Hottentot  tribes  the  women  are  made  to  paint  their 
faces  with  a  spectacle-like  design  at  the  time  of  menstruation.  Many  sav- 
age tribes  believe  that  if  a  man  by  any  accident  comes  upon  menstrual  blood, 
he  will  be  unlucky  in  warfare  and  in  all  other  undertakings. 

Ploss  quotes  a  work  by  Eckarth,  published  early  in  the  eighteenth  century, 
in  which  the  virulence  of  the  menstrual  discharge  is  illustrated  by  the  fact 
that,  unlike  other  blood,  no  amount  of  washing  can  remove  entirely  the  stain 
it  produces  upon  cloths.  The  same  author  says  that  if  a  menstruating 
woman  looks  into  a  mirror,  the  latter  will  forever  be  marked  by  two  round 
defects  corresponding  to  the  eyes  of  the  woman.  This  is  somewhat  similar 
to  the  statement  of  Aristotle  that,  if  a. menstruating  woman  looks  mt6  a 
mirror,  not  only  is  the  polish  lost,  but  the  person  who  next  looks  into  the 
mirror  will  be  bewitched.  Pliny,  speaking  of  this  tarnishing  effect  on 
mirrors,  says  that  the  polish  can  be  restored  by  having  the  same  woman  look 
steadily  upon  the  back  of  the  mirror. 

Another  interesting  group  of  superstitions  has  to  deal  with  the  influence 
of  the  menstruous  woman  upon  milk  and  the  milk  supply.  According  to 
Frazer,  the  Kaffir  woman  of  South  Africa  is  not  allowed  to  drink  milk  dur- 
ing menstruation.  If  she  does,  the  cows  from  which  the  milk  came  will 
die.  The  same  custom  prevails  among  the  Bahimas.  Exception  is  made, 
however,  in  the  case  of  the  young  girl  with  her  first  menstruation.  An  old 
cow,  of  small  value,  is  set  aside  for  her  use.  The  underlying  belief  in  these 
cases  is  obviously  that  there  is  a  sympathetic  bond  of  some  sort  between  the 
cow  and  the  milk,  and  that  any  injury  to  the  latter  affects  the  cow  also.  A 
menstruating  woman  is  even  forbidden  to  cross  the  pasture,  for  if  a  drop  of 
menstrual  blood  were  to  fall  on  such  a  place,  any  cow  passing  over  it  would 
be  apt  to  become  diseased  and  die.     ,^ 

Columella,  Graaf,  and  Verheyen,  as  well  as  a  number  of  the  old  Arabian 
authors,  have  likewise  attributed  noxious  qualities  to  the  menstrual  blood 
(Columbat).  According  to  Moreau  de  la  Sarthe,  in  his  "  Hist.  Nat.  de  la 
Femme  "  (Tome  II,  261),  the  negroes  of  the  South  Sea  Islands  and  the 
aborigines  of  South  America  send  their  females  into  separate  huts  and  keep 
them  absolutely  sequestered  during  the  whole  of  the  menstrual  period. 
Some  savage  tribes  in  Africa  distinguish  by  a  red  flag  those  huts  which 
contain  menstruating  women.  The  color  of  the  flag,  evidently,  is  suggested 
by  the  color  of  the  menstrual  discharge. 

Not  all  the  older  writers,  it  must  be  mentioned,  participated  in  the  view 
that  the  menstrual  blood  was  poisonous.  Aristotle  believed  it  to  be  "  as 
pure  as  that  which  flowed  from  any  wound."  Hippocrates  compared  it 
with  that  of  a  slaughtered  victim  ("  sanguis  autem,  sicut  a  victima,  si  sana 
fuerit  mulier").  John  Freind,  in  arguing  against  the  prevalent  theory  of 
the  noxiousness  of  the  menstrual  blood,  asserts  that  the  latter  cannot  be 


THE  SUPERSTITION  AND  FOLKLORE  OF  MENSTRUATION  5 

impure,  "  inasmuch  as  it  is  not  secreted  by  the  help  of  any  gland,  but  breaks 
forth  from  the  capillary  arteries,  and  therefore  retains  the  nature  of  the 
arterious,  i.  e.,,the  most  pure  blood." 

Although  such  superstitions  as  we  have  been  discussing  are  not  so  com- 
mon as  they  were  formerly,  they  are  far  from  being  thoroughly  rooted  out, 
even.  in.  our  own  day.  Ellis  speaks,  for  example,  of  the  regulations  still  in 
force  in  the  sugar  refineries  of  northern  France,  whereby  women  are  for- 
bidden entrance  during  the  boiling  or  cooling  of  the  sugar,  since  the  prox- 
imity of  a  menstruating  woman  would  cause  the  sugar  to  blacken.  Dr. 
Howard  A.  Kelly  tells  me  that  women  are  not  permitted  to  enter  the  silver 
mines  in  Mexico,  as  a  menstruating  woman  would  cause  all  the  silver  to 
disappear  from  the  veins  of  metal.  For  similar  reasons  no  woman  is 
employed  in  the  opium  industry  at  Saigon,  it  being  said  that  the  opium 
would  turn  bitter  if  a  menstruating  woman  were  near. 

To  show  that  even  the  medical  profession  of  modern  times  is  not  quite 
free  from  the  influence  of  such  superstition,  Ellis  quotes  several  letters 
written  to  the  British  Medical  Journal  as  late  as  1878.  The  writer  of  one, 
a  member  of  the  British  Medical  Association,  asked  whether  it  was  true 
that  if  a  woman  cured  hams  while  menstruating,  the  hams  would  be  spoiled. 
She  had  known  this  to  happen  twice.  Another  medical  man  wrote  that  if 
this  were  so,  what  would  happen  to  the  patients  of  menstruating  women 
physicians?  Still  a  third  wrote  {British  Medical  Journal,  April  27,  1878)  : 
"  I  thought  the  fact  was  so  generally  known  to  every  housewife  and  cook 
that  meat  would  spoil  if  salted  at  the  menstrual  period,  that  I  am  surprised 
to  see  so  many  letters  on  the  subject  in  the  Journal.  If  I  am  not  mistaken, 
the  question  was  mooted  many  years  ago  in  the  periodicals.  It  is  undoubt- 
edly the  fact  that  meat  will  be  tainted  if  cured  by  women  at  the  catamenial 
period,  whatever  the  rationale  may  be.  I  can  speak  positively  as  to  the 
fact"    ./ 

Knott  also  speaks  of  the  prevalence  of  a  singular  superstition  in  certain 
rural  communities  in  England  (Wessex  and  Worcestershire),  where  men- 
struating women  are  believed  to  have  the  power  of  "  measling "  meats, 
Laurent,  again,  mentions  a  number  of  modern  instances  in  which  such 
baneful  influences  were  attributed  to  the  menstruating  woman  —  the  case  of 
the  orchestral  performer  on  the  double  bass  who  noticed  that  whenever  he 
left  a  tuned  double  bass  in  his  lodgings  during  his  wife's  period,  a  string 
snapped ;  that  of  the  woman  harpist  who  was  obliged  to  give  up  her  pro- 
fession because  at  her  periods  the  strings  of  her  harp,  and  always  the  same  > 
strings,  broke ;  the  cases  in  which  women  at  this  period  notice  the  supposedly 
spontaneous  breakage  of  glasses,  the  stopping  of  clocks,  etc. 

Many  other  such  superstitions  might  be  mentioned  —  the  belief  in  the 
poisonous  effect  of  menstrual  blood  upon  cockroaches;  the  theory  of  Am- 
broise  Pare,  that  coitus  with  a  menstruating  woman  would  bring  forth 
monsters ;  the  souring  of  milk  by  the  proximity  of  a  menstruating  woman, 
etc. 


6  MENSTRUATION  AND  ITS  DISORDERS 

The  old  belief  in  the  dangerous  qualities  of  menstruation,  together  with 
the  disagreeable  nature  of  the  process  to  the  woman,  is  perhaps  chiefly 
responsible  for  the  euphemistic  manner  in  which  women,  especially  of  the 
lower  classes,  are  accustomed  to  speak  of  it  among  themselves.  As  Have- 
lock  Ellis  points  out,  the  very  word  "menses"  ("monthlies")  is  in  itself 
a  euphemism.  Schweig  remarks  that  in  both  Latin  and  Germanic  countries, 
the  function  was  commonly  designated  by  some  term  equivalent  to 
"  flowers,"  indicating,  perhaps,  that  it  was  a  species  of  blossoming,  with 
the  possibility  of  bearing  fruit.  German  peasant  women,  for  example, 
according  to  Schweig,  speak  of  menstruation  as  the  "  rosenkrantz  "  or  rose 
wreath.  The  Italian  women,  he  further  remarks,  give  it  the  more  high 
sounding  and  dignified  designation  of  "  marchese  magnifico,"  while  the 
Germans  of  higher  class  sometimes  use  the  expression  "  I  have  had  a  letter  " 
to  denote  the  advent  of  the  period. 

Similar  expressions,  as  is  well  known,  are  made  use  of  among  many 
women  in  our  own  country  —  such  expressions  as  "  coming  around," 
"having  company,"  etc.  It  is  interesting  to  note  that  such  euphemisms  are 
employed  even  among  savage  peoples.  Ellis  quotes  Hill  Font  as  recording 
the  use  among  the  Indians  of  such  expressions  as  "  putting  on  the  moc- 
casin," "  putting  the  knees  together,"  and  "  going  outside,"  the  last  evi- 
dently referring  to  the  custom  of  secluding  the  woman  in  a  solitary  hut  at 
this  period. 

There  is  one  other  of  these  ancient  superstitions  which  must  be  commented 
upon,  and  that  is  the  association  which  has  always  been  made  in  folklore 
between  woman  and  the  serpent.  Whether  it  was  the  Satanic  role  of  the 
serpent  in  the  episode  of  the  Garden  of  Eden  which  was  responsible  for  this 
association  with  the  descendants  of  Eve,  it  is  difficult  to  say,  though  this 
seems  a  logical  assumption.  In  Germany,  it  was  believed  up  to  the  eight- 
eenth century  that  if  one  planted  in  the  soil  a  hair  from  the  head  of  a  men- 
struating woman,  it  would  be  converted  into  a  snake.  Among  certain  tribes 
in  South  Australia  menstruation  is  thought  to  be  due  to  the  scratching  of 
the  vagina  by  a  bandicoot,  which  thus  causes  the  blood  to  flow  (Ellis). 
In  Portugal  it  is  believed  that  women  during  menstruation  are  especially 
apt  to  be  bitten  by  lizards,  and  they  guard  against  this  risk  by  wearing 
drawers  during  the  period  (Ploss).  It  has  been  pointed  out  that  in  various 
widely  separated  parts  of  the  world,  the  snake  is  believed  to  be  the  original 
cause  of  menstruation,  although  no  adequate  explanation  is  offered  for  this 
deep  rooted  superstition. 

From  the  belief  that  menstrual  blood  is  very  poisonous,  it  was,  as  Ploss 
remarks,  only  a  short  step  to  the  supposition  that  it  might  exert  a  powerful 
influence  against  sickness.  In  an  age  when  physical  disease  was  commonly 
looked  upon  as  the  result  of  the  activity  of  evil  spirits,  it  is  not  surprising 
that  the  most  trustworthy  remedies  for  driving  out  these  enemies  of  man 
were  usually  the  most  disgusting.  Menstrual  blood,  according  to  Pliny, 
was  recommended  for  the  following  diseases,  among  others :   gout,  goitre, 


THE  SUPERSTITION  AND  FOLKLORE  OF  MENSTRUATION  7 

hemorrhages,  inflammations  of  the  sahvary  glands,  erysipelas,  furuncles, 
puerperal  fever,  hydrophobia,  epilepsy,  worms,  headache,  etc.  As  a  remedy, 
Velsh  gave  menstrual  blood  the  name  of  "  Zenith."  It  w^as  prepared  by 
extracting  the  dried  blood  from  cloths  by  means  of  Rhein  wine  or  vinegar. 

The  first  napkin  worn  by  a  healthy  virgin  was  put  aside  "  for  use  in  cases 
of  plague,  malignant  carbuncles,  and  other  diseases;  it  was  damped  with 
water  and  laid  on  the  part ;  the  discharge  was  also  used  as  a  topical  applica- 
tion in  acute  gout"  (Crawfurd).  Avicenna  recommended  menstrual 
blood  as  an  external  application  for  sores  of  all  kinds.  For  the  cure  of 
quartan  fever,  Ictidas,  according  to  Crawfurd,  recommended  coitus  with  a 
woman  who  was  just  beginning  to  menstruate.  The  same  author  states 
"  that  medicine  men,  when  about  to  compound  their  medicines,  were  in  the 
habit  of  making  a  saving  clause  that  the  remedy  would  be  effective,  provided 
no  menstruating  woman  approached  their  chamber  during  the  compounding 
process." 

Not  only  as  a  medicament,  but  also  as  a  charm,  was  menstrual  blood  con- 
sidered potent.  A  garment  stained  with  the  menstrual  blood  of  a  virgin 
is  considered,  in  parts  of  Bavaria,  a  certain  safeguard  against  cuts  and  stabs. 
It  will  also  extinguish  fire,  and  is  valuable  as  a  love  philter  (Ellis).  Strack 
gives  instances,  occurring  even  in  the  Germany  of  today,  of  girls  who  admin- 
istered drops  of  menstrual  blood  in  coffee  to  their  sweethearts,  in  order  to 
retain  their  affections.  It  is  even  said  (Ellis)  that  a  sect  of  Valentinians 
attributed  Sacramental  virtues  to  menstrual  blood,  and  partook  of  it  as  the 
blood  of  Christ. 

Pliny  speaks  of  the  general  belief  among  the  Greeks  and  Romans  that  a 
menstruating  woman  could  quiet  a  tempest,  and  that  she  could  therefore 
rescue  a  ship  beset  by  storm  and  wave.  Daniel  Becker  (quoted  by  Ploss) 
states  that  if  a  cloth  stained  with  menstrual  blood  be  fixed  on  a  pole  in  a 
field,  the  hares  will  congregate  to  this  place  in  such  numbers  that  they  can 
easily  be  shot,  and  even  caught  in  the  hand.  In  certain  countries,  especially 
Italy,  cloths  stained  with  menstrual  blood  are  said  by  Eckarth  to  have 
formerly  been  sold  as  charms  against  evil  spirits.  All  these  superstitions 
applied,  especially,  to  the  menstrual  blood  passed  at  the  first  period. 

One  more  instance  of  the  superstitious  belief  in  the  magical  potency  of 
menstrual  blood  may  be  cited  from  the  prolific  Pliny.  He  states  that  "  if  a 
man  takes  a  frog  and  transfixes  it  with  a  reed  entering  its  body  at  the  sexual 
parts  and  coming  out  of  the  mouth,  and  then  dips  the  reed  in  the  menstrual 
discharge  of  his  wife,  she  will  be  sure  to  conceive  an  aversion  for  all 
paramours." 

A  monthly  purgation  of  impurities,  through  th^  medium  of  menstruation, 
was  looked  upon  by  many  of  the  old  writers  as  necessary  for  the  promotion 
of  conception.  As  Freind  pointed  out,  however,  if  this  were  true,  "  no 
woman  would  conceive  except  those  who  had  undergone  it,  which  is  wholly 
repugnant  to  experience."  Other  authors  (Astruc)  suggest  that  concep- 
tion is  promoted  either  by  "  forcibly  exciting  the  woman  to  coition  "  or  by 


8  MENSTRUATION  AND  ITS  DISORDERS 

the  fact  that  the  menstrual  discharge  opens  up  the  uterine  canal,  so  that  the; 
spermatozoon  has  freer  entrance  into  the  uterus." 

]\Iention  must  also  be  made  of  the  theory  of  Galen  and  his  followers,  that 
*'  the  menses  are  given  to  women,  that  they  may  be  evacuated  for  their 
health's  sake  and  yield  nourishment  to  the  embryo  when  suppressed  by  con- 
ception." This  is  the  view  supported  later  by  John  Freind.  Hippocrates 
himself  believed  that  "  if  a  woman  with  child  have  her  menses,  it  is  impos- 
sible that  the  fetus  shall  be  well,  because  the  growth  of  the  fetus  is  abated 
by  the  menses."  In  the  same  belief  Celsus  stated  that  "  if  milk  flow  from, 
the  breasts  of  a  woman  with  child,  whatever  she  bears  must  be  weakly." 

Leaving  aside  these  differences  of  opinion  with  regard  to  the  "  raison 
d'etre  "  of  menstruation  and  turning  to  the  direct  or  "  efficient "  causes  of 
the  phenomenon,  it  is  of  interest  to  note  that  at  least  one  of  the  theories 
prominently  discussed  among  the  medical  profession,  even  up  to  the  first 
quarter  of  the  nineteenth  century,  was  virtually  of  folklore  origin.  Cer- 
tainly it  was  supported  by  no  scientific  observations.  I  refer  to  the  theory 
that  the  rhythm  of  menstruation  is  under  the  influence  of  the  moon. 

The  fact  that  the  length  of  the  menstrual  cycle  corresponds  to  one  lunar 
month  led  many  of  the  older  writers  to  attribute  to  the  moon  a  powerful 
causative  influence  on  the  process.  "  Luna  vetus  vetulas,  juvenas  nova 
luna  repurgat  ".  The  absurdity  of  this  theory,  in  accordance  with  which 
all  women  in  the  same  locality  would  menstruate  at  the  same  time,  does  not; 
seem  to  have  appealed  to  them. 

The  celebrated  Dr.  Mead  wrote  a  treatise  on  "  the  influence  of  the  sun; 
and  moon  on  human  beings,"  wherein,  according  to  the  prevailing  notions 
of  the  time,  he  labored  to  show  that  both  luminaries  exert  much  action  upon 
animals.  In  speaking  of  their  influence  on  periodic  hemorrhages,  he  says 
"and  this  action  of  the  moon  pertains  even  to  those  quadrupeds  that  men- 
struate, for  it  has  been  observed  that  they  generally  have  those  evacuations 
about  the  new  moon,  in  particular,  mares  and  monkeys,  and  so  con- 
stantly that,  according  to  the  testimony  of  Horus  Apollo,  the  Egyptians 
painted  the  cynocephakis  to  represent  the  moon  upon  account  of  a  certain 
symptom,  whereby  the  female  of  this  animal  has  evacuations  of  blood  from 
the  uterus  at  the  new  and  full  moon;  and  they  kept  monkeys  in  their 
temples  in  order  to  point  out  the  times  of  the  conjunctions  of  the  sun  and: 
moon,  whereon  the  moon's  influence  is  apparent  in  all  animals,  provided 
irregularities  in  their  way  of  living  do  not  prevent  it." 

Among  the  old  authors  who  adhered  to  the  theory  of  lunar  influences  on 
the  menses  may  be  mentioned  Aristotle,  Van  Helmont,  and  others.  /  Gall, 
while  not  admitting  any  such  influence,  believed  that  the  discharge  takes 
place  generally  at  about  the  same  time  in  all  women,  and  that  there  are 
certain  weeks  in  which  no  women  are  menstruating.  He  divides  the  men- 
strual epochs  into  two  groups,  embracing  the  first  eight  days  of  the  first  and 
second  fortnights,  respectively,  i.  e.,  the  first  and  third  weeks  of  the  month. 
If  women  happen  to  menstruate  during  the  second  and  fourth  weeks,  the 


THE  SUPERSTITION  AND  FOLKLORE  OF  MENSTRUATION  9 

occurrence  is,  according  to  Gall,  accidental,  for  after  some  months  they 
again  fall  under  the  obedience  of  the  general  law. 

The  other  theories  as  to  the  cause  of  menstruation  which  held  sway  dur- 
ing the  earlier  portion  of  the  last  century  —  the  ferment  theory  and  the 
well  known  plethora  theory  of  Galen — were  scarcely  less  far  fetched  than 
the  one  just  discussed,  but,  inasmuch  as  they  possessed  at  least  a  pseudo- 
scientific  basis,  they  can  scarcely  be  included  in  a  discussion  of  the  folklore 
of  menstruation.     They  will  be  discussed  in  Chapter  VI. 

The  really  scientific  study  of  menstruation  dates  from  the  work  of  Negrier, 
in  1832,  although  the  twentieth  century,  young  as  it  is,  has  yielded 
perhaps  the  most  valuable  contributions  which  have  been  made  to  our 
knowledge  of  the  cause  and  mechanism  of  this,  one  of  the  least  understood 
of  the  phenomena  of  the  human  body.  Modern  methods  of  scientific  inves- 
tigation are  gradually  sweeping  away  the  cobwebbery  of  mystery  and  super- 
stitition  which  has  accumulated  about  the  subject  in  its  passage  down  the 
folk  paths  of  the  centuries.  On  the  other  hand,  can  we  reasonably  doubt 
that  our  present  fine  spun  theories  of  menstruation  will  excite  among 
medical  historians  of  the  future,  the  same  compassion  which  we  now  bestow 
upon  the  crude  beliefs  of  our  scientific  forbears  ? 

I 

LITERATURE 

Crawfurd.     The  Superstitions  of  Menstruation.     Lancet,  1915,  2,  1331. 

Ellis.     Psychology  of  Sex.     v.  i,  2,  6. 

Freind.     Emmenologia.     Eng.  trans,  by  T.  Dale,  1729. 

Frazer.     Golden  Bough. 

Hippocrates.     De  Morbis  Mulierum. 

Knott.     The  Folk-Loreof  Menstruation.     Med.  Press  and  Circ,  1910,  89,  152. 

Laurent.  Les  forces  inconnues  de  quelques  phenomenes  mecaniques, 
produites,  sans  contact,  par  certaines  femmes  au  moment  de  la  men- 
struation.    Chron.  med.,  Par.,  1897,  4,  769. 

Pliny.     Hist,  nat,  v.  7,  19,  23. 

'Ploss.     Das  Weib  in  der  Natur  und  Volkerkunde.     Leipz,,  1895. 


CHAPTER  II 

PERIODIC  SEXUAL  PHENOMENA  IN  THE  LOWER  ANIMALS 

General  Considerations. —  Much  of  what  we  know  regarding  the  physi- 
ology of  menstruation  has  been  learned  from  studies  upon  the  lower 
animals,  and  is  based  upon  the  assumption  that  there  is  a  close  analogy 
between  the  phenomenon  of  menstruation  and  that  of  heat  or  estrus,  as 
exhibited  by  the  lower  animals.  As  we  shall  see,  there  is  much  evidence, 
both  anatomical  and  physiological,  to  support  this  view.  The  application  of 
the  comparative  method  of  study  to  this  problem  is  of  exceeding  interest. 
As  might  be  expected,  the  primitive  manifestations  of  the  function  of  estro- 
menstruation  are  very  feeble.  As  we  ascend  in  the  scale  of  animal  life, 
however,  there  is  a  steady  and  orderly  evolution  of  the  process,  correspond- 
ing to  the  gradually  increasing  perfection  of  development  of  the  repro- 
ductive apparatus.  The  human  species  presents  the  highest  type  of  develop- 
ment of  the  organs  concerned  in  this  periodic  phenomenon,  as  well  as  of 
the  process  itself. 

Importance  of  a  Study  of  the  Comparative  Physiology  of  Menstrua- 
tion.—  Such  comparative  studies  give  a  strong  promise  that  the  physiology 
of  menstruation  may  be  brought  within  the  domain  of  scientific  knowledge, 
and  thus  cease  to  be  the  mystery  which  it  has  been  for  so  many  ages.  The 
possibilities  for  good  resulting  from  such  investigations  are  great.  Most 
important  of  all,  a  knowledge  of  the  real  nature  of  the  menstrual  process 
will  give  us,  at  once,  a  rational  basis  for  the  therapeutics  of  the  numerous 
menstrual  aberrations.  Imperfect  as  our  knowledge  still  is,  a  new  and  intel- 
ligent point  of  view  is  gained  —  and  gained  only  — by  a  familiarity  with 
the  analogous  phenomenon  in  the  lower  animals.  No  further  justification 
is  necessary  for  a  brief  survey  of  what  we  know  concerning  the  periodic 
sexual  phenomena  exhibited  by  the  lower  animals,  and  the  application  of 
these  facts  to  the  study  of  the  corresponding  phenomena  in  the  human 
female. 

Earliest  Manifestations  of  Periodic  Sex  Activity. —  Sexual  phe- 
nomena of  a  periodic  nature  are  found  throughout  the  entire  animal  king- 
dom, although  the  primary  manifestations  of  such  functions  are,  as  has 
already  been  said,  rather  feebly  marked.  In  the  class  of  animals  below  the 
mammalian  group,  there  is  of  course  nothing  corresponding  very  closely 
to  an  actual  menstrual  flow.  However,  such  a  flux  would  scarcely  be 
looked  for  in  them,  since  they  possess  no  uterus.  In  the  generative  canals 
of   these  animals,   nevertheless,    local   manifestations   of  the   reproductive 

10 


PERIODIC  SEXUAL  PHENOMENA  IN  THE  LOWER  ANIMALS  11 

functions  are  often  exhibited  in  other  ways,  as  by  an  increased  vascularity 
and  pigmentation  about  the  genital  orifices. 

Wiltshire  and  others  have  called  attention  to  the  general  relation  of 
pigmentation  to  the  reproductive  function.  In  many  instances  this  is  very 
striking.  Darwin,  for  example,  says  (Descent  of  Man,  page  229)  "many 
birds  acquire  bright  colors  and  other  decorations  in  the  breeding  season 
alone;"  and  (page  496)  "certain  ornamental  appendages  often  become 
enlarged,  turgid  and  brightly  colored  during  the  act  of  courtship."  Even 
in  insects,  this  sexual  pigmentation  is  often  very  conspicuous.  It  is 
interesting  to  note  that  the  exquisite  beauty  of  flowers,  as  well  as  their 
perfume,  are  looked  upon  as  sexual  phenomena.  The  same  may  be  said  of 
the  bright  colors  acquired  by  many  birds  during  the  mating  season.  In  this 
connection,  Darwin  (page  265)  says  "The  sedentary  annelids  become 
duller  colored,  according  to  M.  Ouatrefages,  after  the  period  of  reproduc- 
tion; this,  I  presume,  may  be  attributed  to  their  less  vigorous  condition  at 
that  time." 

Many  animals  of  the  higher  class  of  mammalia,  as  we  shall  see,  show 
the  same  tendency  toward  coloring  of  the  external  genitalia  in  connection 
with  the  reproductive  change.  In  other  animals,  such  as  reptiles,  sexual 
activity  is  accompanied  by  an  increase  in  the  cutaneous  secretions,  especially 
of  an  odorous  variety.  Laycock  states  "  many  tortoise  smell  of  musk, 
which  probably  proceeds  from  follicles  in  connection  with  the  cloaca. 
Several  lizards,  among  others  the  iguana,  have  a  row  of  small  follicles  with 
round  orifices  at  the  inner  side  of  the  thigh,  which  secrete,  especially  at  the 
coupling  season,  an  odorous,  fatty  liquid."  Darwin  states  (Descent  of 
Man,  page  52)  "  during  the  breeding  season  the  anal  scent  glands  of  snakes 
are  in  active  function,  and  so  it  is  with  the  same  glands  in  lizards." 

Periodic  Sexual  Activity  in  the  Lower  Mammals. —  The  lowest  type 
of  mammal  concerning  which  anything  of  a  definite  nature  is  known  with 
regard  to  such  sexual  phenomena  as  we  are  now  studying  is  the  marsupial. 
The  investigations  of  Wiltshire  seem  to  show  that  these  animals  exhibit  a 
definite  period  of  "heat,"  and  an  estrual  discharge  has  been  observed. 
Incidentally,  the  development  of  the  sexual  apparatus  in  these  animals  is 
somewhat  more  advanced,  there  being  now  a  vagina,  although  it  enters  into 
the  sinus  urogenitalis.  Practically  all  creatures  of  the  mammalian  family 
exhibit  these  periods  of  heat  or  sexual  excitement  to  a  greater  or  less  degree. 
Most  of  the  studies  which  have  been  made  have  been  upon  domesticated 
animals,  or  upon  wild  animals  in  captivity.  It  is  important  to  remember, 
because  it  has  a  bearing  on  the  analogous  phenomena  in  the  human  female, 
that  the  sexual  seasons  of  animals  may  be  greatly  influenced  by  such  condi- 
tions as  the  climate,  the  region  in  which  the  animal  lives,  its  supply  of  food, 
general  comfort,  and  other  conditions  which  differ  in  wild  as  compared  to 
domesticated  animals. 

"  Heat "  or  Estrus. —  The  classical  work  of  Heape,  from  which  I 
shall  quote  freely  in  this  chapter,  has  placed  the  study  of  the  sexual  season 


12  MENSTRUATION  AND  ITS  DISORDERS 

in  the  lower  animals  upon  a  firm  footing.  According  to  this  observer,  the 
reproductive  period  of  all  mammals,  whether  male  or  female,  indicates  the 
whole  of  that  period  during  which  the  generative  organs  are  capable  of 
the  reproductive  function.  It  must  be  remembered,  however,  that  gestation 
is  not  possible  at  all  times  throughout  the  reproductive  period.  At  certain 
intervals  the  generative  organs  of  animals  exhibit  a  special  activity,  while 
at  other  times,  again,  they  are  inert  and  fallow.  In  other  words,  at  periodic 
intervals,  as  the  result  of  the  action  of  some  peculiar  and  as  yet  unknown 
stimulus,  there  is  an  increase  in  the  activity  of  the  sexual  glands,  culminat- 
ing in  sexual  desire,  and  resulting  in  coition  and  gestation.  The  time  during 
which  the  sexual  organs  of  an  animal  exhibit  this  special  activity  Heape 
speaks  of  as  the  sexual  season.  It  is  commonly  spoken  of  as  the 
period  of  heat,  desire,  or  estrus.  The  term  rut  (German  brunst)  is  often 
applied  to  this  state,  but  Heape  states  that  this  is  erroneous,  inasmuch 
as  this  word  should  have  reference  only  to  the  phenomena  exhibited  by  the 
male.  The  word  is  derived  from  the  Latin  rugire,  meaning  to  roar  or 
to  bellow,  and  as  Heape  says,  it  is  perhaps  literally  applicable  only  to  such 
animals  as  dogs  and  boars. 

In  this  discussion  we  are  concerned  more  especially  with  the  phenomena 
incident  to  the  sexual  season  of  the  female.  There  are  two  principal  types 
of  sexual  season  exhibited  by  the  mammalian  female,  the  simple  or  anes- 
trous  and  a  more  complicated  form  known  of  as  the  .diestrous. 

The  Anestrous  Cycle. —  The  Pro'estrum. —  In  the  simple  form,  the 
sexual  season  is  ushered  in  by  the  pro'estrum,  or  pro-estrous  period.  During 
this  stage,  certain  well  marked  phenomena  make  themselves  evident  in  the 
external  generative  organs  and  the  surrounding  parts.  The  first  change 
usually  noted  is  swelling  and  congestion  of  the  vulva,  with  more  or  less 
general  excitement  and  restlessness;  in  addition  to  these,  there  are  various 
other  signs  characteristic  of  special  animals,  such  as  the  congested  con- 
junctiva of  the  rabbit,  the  drooping  ear  of  the  pig,  etc.  In  monkeys, 
especially,  there  is  often  congestion  of  the  face  and  nipples,  as  well  as  of 
the  buttocks  and  anal  region.  These  parts  are  often  brilliantly  colored, 
as  may  be  observed  by  the  visitor  to  zoological  gardens. 

This  primary  swelling  and  congestion  of  the  external  genitalia  is,  in 
most  animals,  followed  by  a  discharge  from  the  generative  tract.  The  nature 
of  the  discharge  differs  in  different  animals.  In  some  it  is  made  up  only 
of  mucus  from  the  uterine  glands  and  those  in  the  lower  portion  of  the 
generative  tract.  Epithelial  cells  are  often  found  in  this  discharge,  coming 
either  from  the  uterus  or  from  the  vagina.  Finally,  in  addition  to  the  above, 
blood  is  in  certain  animals  a  more  or  less  conspicuous  constituent  of  the 
discharge.  Blood  has  been  observed  in  the  pro-estral  discharge  of  the  mare, 
ass,  cow,  sheep,  bear,  pig,  cat,  rabbit,  kangaroo,  bitch,  and  in  many  types 
of  monkey.  It  is  probable  that  careful  examination  of  the  discharge  would 
show  the  presence  of  blood  elements  in  many  other  animals,  as  the  recent 
painstaking  investigation,  carried  out  on  guinea  pigs  by  Stockard  and 


PERIODIC  SEXUAiL  PHENOMEN-A  IN  THE  LOWER  ANIMALS  13 

Papanicolau,  would  indicate.  In  some  of  these  animals  the  blood  is  present 
in  very  small  amounts,  scarcely  enough  to  tinge  the  discharge.  In  others, 
however,  as  in  the  bitch  and  in  certain  monkeys,  the  flow  of  blood  is  quite 
free.  Raciborski  (quoted  by  Ellis)  observed  in  the  Jardin  des  Plantes  that 
"  the  menstrual  hemorrhage  in  guenons  was  so  abundant  that  the  floor  of 
the  cage  was  covered  by  it  to  a  considerable  extent."  Moll  also  speaks  of 
a  pair  of  orangoutangs  in  the  Berlin  Zoological  Gardens,  the  female  of 
which  menstruated  regularly,  like  a  woman,  and  also  refrained  from  inter- 
course at  the  periods.  At  other  times  coitus  was  quite  regular,  every  two 
or  three  days.  Not  only  does  the  character  of  the  discharge  differ  in 
different  species  of  animals,  but  also  in  different  members  of  the  same 
species,  and  in  the  same  animals  at  different  times.  This  applies  to  both 
quantity  and  quality.     The  analogy  to  human  beings  is  quite  evident. 

The  duration  of  the  pro-estrum  appears  to  be  subject  to  great  variations 
in  different  animals  and  in  the  same  animal  at  different  times.  In  the  rabbit 
it  is  known  to  last  from  one  to  four  days ;  in  the  bitch  from'  seven  to  twelve 
days ;  in  the  monkey  from  six  to  eight  days. 

In  regard  to  the  internal  phenomena  associated  with  the  pro-estrum, 
Heape  makes  a  division  into  four  principal  stages :  the  period  of  rest,  the 
period  of  growth,  the  period  of  degeneration,  and  the  period  of  recupera- 
tion. The  resting  stage  is  that  which  immediately  precedes  the  pro-estrum, 
of  which  it  is  therefore  really  not  a  part.  During  this  period  the  mucous 
membrane  of  the  uterus  is  opaque,  white,  and  anemic.  During  the  period 
of  growth^  the  stroma  of  the  endometrium  takes  on  active  hypertrophy, 
there  is  marked  increase  in  vascularity,  and  the  mucosa  as  a  whole  becomes 
thick,  soft,  and  congested.  In  the  period  of  degeneration,  there  is  a  break- 
ing down  of  the  vessel  walls  with  an  extravasation  of  blood,  which  becomes 
collected  in  little  lacunae;  the  latter  rupture,  and  the  blood  breaks  through 
the  degenerated  epithelium  to  the  surface.  The  recuperative  stage,  as  its 
name  indicates,  is  characterized  by  regenerative  changes  in  the  epithelium 
and  stroma.  During  this  period  the  blood  is  expelled,  the  uterus  again 
assuming  the  appearance  described  in  connection  with  the  period  of  rest. 
These  changes  I  have  described  thus  fully  because  of  their  relation  to  the 
corresponding  changes  in  women. 

The  Period  of  Estrus. —  The  pro-estrum  is  followed  by  the  period  of 
estrus,  which  is  the  climax  of  the  process.  This  is  the  period  of  sexual 
desire,  and  it  is  only  at  this  time  that  the  female  is  willing  to  receive  the 
male.  The  duration  is  very  variable,  continuing  from  a  few  hours  to 
several  weeks.  It  is  interesting  to  know  that,  while  the  period  of  desire 
normally  follows  pro-estrum,  it  is  sometimes  evident  without  the  pro-estrum 
having  taken  place.  This  "  abnormal  estrus  "  is  most  commonly  seen  in 
connection  with  congestive  or  irritative  changes  in  the  generative  organs. 
Whether  congestion,  in  itself,  is  sufficient  to  produce  estrus,  or  whether 
some  peculiar  stimulus  through  the  blood  or  nervous  system  is  needed,  can- 
not be  definitely  stated.     As  a  rule,  breeders  look  upon  estrus  as  merely 


14  MENSTRUATION  AND  ITS  DISORDERS 

an  accompanying  phenomenon  of  pro-estrum,  rather  than  as  a  result  of  it. 
After  the  congestion  and  stimulation  of  the  generative  organs  associated 
with  pro-estrum  has  quieted  down,  it  would  seem  that  the  organs  regain  a 
renewed  stimulus,  and  it  is  then  that  estrus  takes  place.  It  is  not  until 
after  the  swelling  of  the  vulva  and  surrounding  tissues  has  been  absent 
for  some  time  that  coitus  is  permitted  by  most  animals.  As  a  matter  of  fact, 
where  a  considerable  discharge  of  blood  is  present,  coitus  does  not  take 
place  until  the  discharge  has  almost,  if  not  entirely,  been  evacuated. 

The  Metcstrum  and  Di-estrum. —  If  impregnation  does  not  occur  during 
estrus,  the  latter  is  followed  by  a  period  during  which  the  activity  of  the 
generative  organs  subsides  for  a  definite  time.  This  is  called  the  metestrum, 
or  the  metestrous  period.  In  the  simple  type  of  sexual  season  which  we  are 
now  considering,  the  metestrum  is  in  turn  followed  by  a  prolonged  period 
of  quiescence,  which  is  spoken  of  as  the  anestrum,  or  the  anestrous  period. 
The  duration  of  this  is  very  variable,  in  some  animals  two,  in  others, 
perhaps  eleven  or  more  months.  This  period  of  quiescence  is  finally  dis- 
turbed by  the  onset  of  a  new  pro-estrum. 

The  Di-estrous  Cycle. —  In  the  more  complicated  form  of  sexual 
season  certain  variations  from  the  above  order  of  events  are  observed. 
Pro-estrum  ushers  in  the  sexual  season,  and  is  followed  by  estrus,  as  in  the 
simple  form.  This  in  turn  is  followed  by  the  metestrum.  After  this,  how- 
ever, instead  of  a  long  anestrous  period,  as  in  the  simple  type,  only  a  short 
period  of  quiescence  occurs,  lasting  perhaps  only  a  few  days,  seldom  more 
than  twelve  at  the  most.  This  is  spoken  of  as  the  period  of  di-estrum, 
or  the  diestrous  period.  Following  this  immediately  comes  a  new  pro- 
estrum,  the  four  periods  —  pro-estrum,  estrum,  metestrum,  and  di-estrum  — 
constituting  the  so-called  di-estrous  cycle.  Unless  conception  should 
occur,  this  cycle  is  repeated  two  or  more  times,  and  may  occupy  any 
time  from  one  month  to  an  entire  year.  If  it  occurs  only  during  a 
month  or  so,  it  is  limited  to  one  particular  season  of  the  year;  if,  on  the 
other  hand,  it  takes  place  throughout  the  entire  year,  it  fills  the  entire 
reproductive  period  of  the  animal.  This  is"  the  condition  of  affairs  in  the 
human  female  when  the  return  of  the  period  is  not  interrupted  by  gestation. 

The  Estrous  Cycle  in  Various  Animals. —  Animals  in  which  only  one 
estrus  occurs  during  each  sexual  season,  or  in  other  words,  those  which 
exhibit  the  anestrous  cycle,  are  spoken  of  as  monestrous.  Those,  on  the 
other  hand,  which  exhibit  a  series  of  di-estrous  cycles,  are  called  poly- 
estroiis.  It  is  generally  believed  that  these  two  types  of  sexual  season 
are  modifications  of  one  another,  as  a  result  of  the  influence  produced  by 
conditions  of  life.  For  instance,  the  red  deer,  according  to  Heape,  is 
monestrous  in  the  wild  state,  while  in  captivity  it  is  polyestrous.  Among 
monestrous  animals  may  be  mentioned  the  bitch,  which  has  two  sexual 
seasons  each  year,  one  in  the  spring  and  one  in  the  autumn,  although  there 
are  many  exceptions  to  this  rule;  some  bitches  exhibit  only  one  sexual 
season  each  year,  while  in  others  they  may  occur  at  intervals  of  from  four 


PERIODIC  SEXUAL  PHENOMENA  IN  THE  LOWER  ANIMALS  15 

to  eleven  months.  The  wolf  and  fox  are  also  monestrous.  The  cat,  in  the 
wild  state,  is  said  to  have  one  season  per  year,  although  there  seems  to  be 
some  doubt  upon  this  point;  when  domesticated  the  cat  exhibits  three  or 
four  sexual  seasons  each  year.  Among  the  polyestrous  animals  may  be 
mentioned  horses,  cattle,  sheep,  pigs,  certain  types  of  deer,  giraffes,  elephants 
and  kangaroos.  In  its  most  highly  developed  form,  however,  the  polyes- 
trous type  is  observed  in  monkeys  and  in  the  human  female. 

The  duration  of  the  di-estrous  cycle  differs  in  different  animals.  For 
instance,  in  the  domesticated  mare  and  cow  it  is  three  to  four  weeks;  in 
the  sheep  and  pig,  two  to  four  weeks ;  in  monkeys  it  appears  to  be  about  one 
month  in  duration ;  while  in  the  human  female,  as  is  well  known,  the  usual 
duration  of  the  menstrual  cycle  is  four  weeks.  In  the  human  female  and 
also  in  certain  types  of  monkeys  the  di-estrous  cycle  is  continuous,  recurring 
all  the  year  around,  although  there  are  many  exceptions  to  this  rule.  Arctic 
explorers  tell  us  that  Esquimaux  women,  living  very  far  North,  do  not 
always  menstruate  during  the  long  Arctic  winters.  Not  more  than  70  per 
cent,  it  is  said  by  Cook,  show  a  persistence  of  menstruation  during  the  long 
dark  depths  of  winter.  It  may  be,  therefore,  that  a  genuine  anestrous 
period  is  exhibited  by  these  women. 

This  is  of  interest  as  seeming  to  indicate  that  conditions  of  life  may  bring 
about  a  transformation  of  one  type  of  sexual  season  into  another,  even  in 
the  human  female.  In  the  same  connection,  Wiltshire  reports  that  in  cer- 
tain savage  tribes  the  women  menstruate  at  intervals  of  several  months,  and 
only  at  long  intervals  in  the  women  of  Lapland,  Greenland,  the  Faroe 
Islands,  Terradelfeugo,  and  in  some  parts  of  Paraguay.  Although  horses, 
cattle,  deer,  and  the  other  animals  above  mentioned,  show  a  consecutive 
recurrence  of  the  di-estrous  cycle  when  in  captivity  or  under  domestication, 
it  is  not  believed  that  this  is  the  condition  which  is  natural  to  them,  but  that 
it  is  the  result  of  the  care  and  attention  which  they  receive  from  man.  As 
a  matter  of  fact,  the  only  animals  known  to  exhibit  the  continuous  recur- 
rence of  the  di-estrous  cycle  in  a  state  of  nature  are  certain  types  of  monkeys. 
The  fact  that  it  is  possible  to  bring  about  such  a  striking  increase  in  the 
capacity  for  estrus  in  animals  through  changes  in  the  conditions  of  life 
makes  it  easy  to  understand  that  the  regular  occurrence  of  the  di-estrous 
cycle  in  monkeys  and  in  the  human  female  is  only  a  step  in  advance  of  the 
more  or  less  regular  di-estrous  and  anestrous  cycles  in  the  lower  animals. 
Although  the  sexual  season  in  the  human  female  is  continuous,  Heape  has 
accumulated  many  interesting  observations  which  seem  to  indicate  the 
vestigial  existence,  as  it  were,  of  a  special  and  limited  sexual  season.  I 
shall  quote  only  a  few  of  them  : — 

"  Feasts,  similar  to  the  erotic  feasts  which  were  indulged  in  by  the 
ancients  —  Babylonians,  Phenicians,  Egyptians,  Greeks,  and  Romans 
(Ploss,  1887)  — •  were  still  practiced  to  some  extent  in  the  sixteenth  century 
in  Russia  and  in  some  parts  of  India  at  a  much  more  recent  date,  while  such 
customs  as  '  gwneyd  bragod '  and  possibly  our  own  *  bean  feasts '  may  not 


16  MENSTRUATION  AND  ITS  DISORDERS 

improbably  be  the  modern  representatives  of  these  ancient  customs  in  our 
own  country. 

"  The  Watch-and-dies  of  West  Australia  and  the  Tasmanians  have  sexual 
feasts  in  the  middle  of  spring  time, 

"  The  Hos,  an  Indian  hill  tribe,  have  a  similar  feast,  which  becomes  a  satur- 
nalia during  which  absolute  sexual  freedom  is  indulged  in,  in  the  month  of 
January;  while  among  the  Santals,  another  hill  tribe,  and  the  Panjas  of 
Jeypore,  a  festival  in  January  is  kept  up  for  a  month,  during  which  promis- 
cuous intercourse  is  allowed. 

"In  New  Caledonia  November  (that  is  late  spring)  used  to  be  the  time 
when  marriage  engagements  were  made,  and  among  the  Rajputs  of  Mewar 
the  last  days  of  spring  are  dedicated  to  the  god  of  love. 

"Among  the  Kaffirs  of  cis-Natalian  Kaffirland  more  children  are  born  in 
August  and  September  than  in  any  of  the  other  months,  and  it  seems  probable 
this  is  due  to  certain  feasts  during  which  there  is  unrestricted  intercourse 
between  the  unmarried  people  of  both  sexes. 

"  My  friend,  Mr.  Caldwell,  tells  me  that  the  Queensland  natives  with  whom 
he  was  brought  in  contact  have  a  distinct  sexual  season  in  September  (that 
is  spring),  and  that  they  cannot  be  prevailed  upon  to  do  any  work  for  some 
weeks  at  that  time  of  the  year." 

Are  the  Phenomena  of  Estrus  and  Menstruation  Analogous?  —  I 
have  gone  thus  fully  into  the  subject  of  the  periodic  sexual  phenomena 
exhibited  by  the  lower  animals  for  the  reason  that  it  has  the  most  funda- 
mental bearing  upon  our  ideas  concerning  menstruation  in  women.  Indeed, 
it  would  seem  to  be  absurd  to  expect  to  be  able  to  appreciate  fully  the  nature 
and  mechanism  of  menstruation  without  some  idea  of  the  corresponding 
phenomena  in  the  lower  animals.  The  question  which  has  perhaps  sug- 
gested itself  before  this  is,  Is  the  evidence  at  hand  sufficient  to  justify  us  in 
the  assumption  that  menstruation  in  zvomen  is  really  the  analogue  of  estrus 
of  the  lozuer  animals?  I  believe  that  the  facts  which  I  have  already  pre- 
sented are  sufficient  to  warrant  us  in  drawing  this  conclusion.  The  argu- 
ments for  and  against  this  idea  are  so  well  presented  by  Heape  that  I  cannot 
do  better  than  to  quote  them  verbatim : 

**  Those  who  uphold  the  homology  do  so  because  — 

"  I.  There  is  congestion  of  the  generative  organs  during  both  *  heat '  and 
menstruation. 

"  II.  There  may  be  a  recurrence  of  *  heat '  as  there  is  a  recurrence  of  men- 
struation. 

"  III.     The  discharge  during  '  heat '  may  be  of  a  menstrual  character. 

*'  IV.     From  a  phylogenetic  point  of  view  the  homology  is  to  be  expected. 

'*  These  statements  may  be  disposed  of  together ;  so  far  as  they  go  they  are 
true  enough,  but  they  are  not  in  themselves,  separately  or  collectively,  conclusive 
evidence. 

"  Those  who  deny  the  homology  do  so  because  — 

"  I.  The  discharge  during  '  heat '  in  the  lower  animals  is  said  to  be  mucus, 
while  in  the  human  female  it  is  mostly  blood. 


PERIODIC  SEXUAL  PHENOMENA  IN  THE  LOWER  ANIMALS  17 

"  2.  The  time  of  '  heat '  is  said  to  be  the  only  time  the  lower  animals  will 
permit  of  coition,  while  sexual  union  during  menstruation  is  a  very  rare 
occurrence. 

"  3.  '  Heat '  or  '  rut '  is  said  to  occur  in  both  males  and  females  in  the  lower 
animals  and  to  depend  upon  the  seasons,  whereas  in  the  human  species  it  is 
said  to  be  not  so. 

"  4.  After  '  heat '  the  female  of  the  lower  animals  is  said  to  refuse  the  male, 
whereas  in  the  human  female  sexual  desire  is  not  confined  to  the  time  of 
menstruation. 

"  5.  Heat  is  necessary  to  the  production  of  the  species  in  the  lower  animals, 
while  in  woman,  *  desire  '  is  said  to  be  not  essential  to  conception. 

*"6.  In  the  lower  animals  the  ovaries  are  said  to  contain  ripe  ova  only  during 
the  time  of  *  heat,'  whereas  ripe  ova  are  said  to  be  found  in  the  human  ovary 
at  all  times  without  reference  to  menstruation. 

"  7.     There  is  said  to  be  no  proof  of  the  identity  of  the  two  conditions. 

"  I  think  these  propositions  fairly  cover  the  ground  over  which  those  who 
deny  the  relationship  of  what  they  call  '  heat '  to  menstruation  have  hitherto 
traveled. 

"  It  will  be  seen  at  a  glance  that  the  denials  originate,  in  most  instances,  in 
misconception  of  the  facts,  and  that  many  of  the  errors  are  due  to  the  misuse  of 
the  terms. 

"  It  will  be  worth  while,  however,  to  answer  each  of  them  separately,  and  the 
following  replies  are  numbered  to  correspond  with  the  numbers  of  the  above 
objections. 

"  I.  The  discharge  in  many  animals  during  the  pro-estrum  contains  blood 
and  sometimes  uterine  tissue ;  it  is  not  always  solely  mucus,  and  when  blood  is 
absent  it  has  been  shown  that  its  absence  is  due  to  a  modification  of,  and  not 
to  any  radical  difference  in,  the  process. 

"  2.  The  term  '  heat '  is  here  wrongly  used ;  it  is  made  to  include  both  the 
pro-estrum  and  the  estrus  in  the  lower  animals,  and  is  compared  in  that  extended 
sense  with  the  term  menstruation.  Coitus  does  not  occur  during  the  pro- 
estrum,  which  corresponds  with  menstruation,  but  during  estrus,  which  imme- 
diately follows  the  pro-estrum.  I  have  shown  above  that  there  is  no  lack  of 
evidence  that  the  same  may  be  true  for  the  human  female. 

"  3.  Although  the  time  for  sexual  intercourse  among  human  beings  is  not 
universally  confined  to  particular  seasons,  I  have  shown  that  in  some  cases  this 
is  so,  and  that  in  all  peoples  there  is  a  marked  disposition  to  indulge  in  sexual 
intercourse  at  particular  times  of  the  year,  which  are  entirely  comparable  to  the 
so-called  *  breeding  seasons '  of  the  lower  animals.  Furthermore,  in  certain 
domesticated  animals  and  certain  wild  animals  kept  in  captivity  the  males  do 
not  '  rut '  only  at  certain  times  of  the  year,  but  are  prepared  to  propagate  at  all 
times  (dog),  or  almost  at  all  times  (captive  cattle  or  deer),  throughout  the  year. 

"  4.  There  is  some  truth  in  this  objection,  but  it  must  not  be  forgotten  that, 
among  the  lower  animals,  while  captivity  reduces  the  violence  of  the  sexual 
passion,  it  increases  its  frequency;  and  that  in  civilized  woman,  in  all  proba- 
bility, it  is  this  variation  of  the  function  still  further  exaggerated  which  is 
responsible  for  the  difference  (see  also  2). 

"5.  Here  again  the  objection  is  largely  due  to  a  mistaken  use  of  the  term 
*  heat,'  which  in  this  case  is  used  to  denote  estrus. 


18  MENSTRUATION  AND  ITS  DISORDERS 

"  Menstruation,  that  is  pro-estrum,  in  women  is  as  necessary  to  the  produc- 
tion of  the  species  as  pro-estrum  in  the  lower  animals  can  be;  the  fact  that 
estrus  is  less  pronounced  in  the  former  is  true,  but  it  is  not  altogether  absent,  as 
has  already  been  referred  to  in  the  replies  to  propositions  numbered  2  and  4. 

"  6.  This  objection  has  reference  to  the  question  of  ovulation,  which  has  not 
been  treated  of  in  this  chapter;  with  regard  to  it  I  would  merely  say,  that 
ovulation  in  certain  of  the  lower  mammals  is  not  necessarily  coincident  with 
estrus,  while  in  some  of  them  estrus  and  ovulation  are  quite  separate  functions. 
Ripe  ova  are  not  found  at  all  times  in  each  human  female,  and  that  they  may 
be  found  at  times  which  are  not  coincident  with  menstruation,  is  merely  further 
evidence  that  these  functions  are  independent  also  in  women.  Further,  the 
degree  of  independence  which  these  two  functions  assume  is  apparently  variable 
in  the  human  female. 

"  7.     The  answer  of  this  objection  is  comtained  in  the  foregoing." 


II 

LITERATURE 

Ellis.     Psychology  of  sex.     1906-11. 

Heape.     The  Anatomy  of  Menstruation  in  Semopithecus  Entellus.     Trans. 

Obst.  Soc.  London,  1894,  36,  213. 
• The  Menstruation  and  Ovulation  of  Macacus  Rhesus.     Proc.  Roy.  Soc, 

1896,  60,  202. 
• The  Menstruation  and  Ovulation  of  Monkeys  and  the  Human  Female. 

Med.  Press  and  Circ,  1898,  65,  378.     Also  in  Brit.  M.  J.,  1898,  2,  1868. 

Sexual  Season  of  Mammals.     Quart.  J.  Microscopic  Science,  1900,  44,  i. 

Keller.     Ueber  den  Bau  des  Endometriums  beim  Hunde,  etc.     Anat.  Hefte, 

1909,  34,  309- 
Marshall.     Comparative  Physiology  of  Menstruation  and  Allied  Processes. 

Internat.  Clin.,  1909,  17  s.,  2,  190. 
Stockard  and  Papanicolau.     a  Rhythmical  *'  Heat  Period  "  in  the  Guinea- 

Pig.     Science,  1917,  46,  42. 
Sutton.     Menstruation  in  Monkeys.     Brit.  Gyn.  J.,  1886-7,  2,  285. 
Webster.     The  Biological  Basis  of  Menstruation.     Montreal  M.  J.,  1897,  25, 

761. 
Wiltshire.     The  Comparative  Physiology  of  Menstruation.     Brit.  M.  J.,  1883, 

I,  395- 


CHAPTER  III 
THE  SOURCE  OF  THE  MENSTRUAL  FLOW 


The    Endometrium    the    Source    of    the    Menstrual    Blood. —  The 

mucous  membrane  of  the  uterus  is  the  immediate  source  of  the  menstrual 
blood.     This  does  not,  however,   apply  to  the  mucous  membrane  of  the 

entire  uterus,  but  only  to  that  which 
lines  the  corpus  uteri  or  body  of  the 
uterus,  i.  e.  that  portion  above  the  level 
of  the  internal  os.  To  this  portion  of 
the  mucosa  the  term  "  endometrium  " 
is  applied. 

The  Role  of  the  Cervix  Uteri. — 
There  is  a  decided  difference  between 
the  structure  of  the  endometrium  and 
that  of  the  cervical  mucosa  or  en- 
docervix.  (Figs,  i  and  2)  Correspond- 
ing to  this  anatomic  difference  between 
the  two  structures,  they  exhibit  also  a 
well  marked  functional  difference,  inas- 
much as  the  cervical  mucosa,  according 
to  most  investigators,  has  no  part, 
under  ordinary  circumstances,  in  the 
production  of  the  menstrual  blood.  It 
is  true  that  from  time  to  time  cases  are 
observed  in  which  menstruation  persists 
even  after  supravaginal  hysterectomy, 
and  that  such  cases  are  explained  by 
some  on  the  theory  that  the  cervix  also 
participates  actively  in  the  menstrual 
process,  and  is  responsible  for  its  con- 
tinuance even  after  removal  of  the  en- 
tire corpus.  It  is  probable  that  in  most 
of  these  cases  a  strip  of  endometrium 
has  been  left  behind,  and  that  it  is  this 
which  keeps  up  menstruation.  As  a 
matter  of  fact,  the  purposeful  retention  of  such  a  bit  of  endometrium  has 
been  recommended  with  the  idea  of  preserving  the  menstrual  function  in 
cases  in  which  supravaginal  hysterectomy  is  necessary.    At  any  rate,  what- 

19 


20 


MENSTRUATION  AND  ITS  DISORDERS 


ever  may  happen  in  the  exceptional  case,  there  is  no  good  reason  to  believe 
that  the  cervix  plays  an  active  part  in  normal  menstruation. 

In  this  connection  it  is  interesting  to  note  that  there  has  been  some  dis- 
cussion as  to  the  ^/^r  of  the  ccnncal  canal  during  incnstritation.  Some  have 
claimed  that  the  lumen  of  the  canal  is  narrowed  by  the  swelling  of  the 
mucous  membrane ;  others  that  it  is  dilated.  Most  of  these  statements 
appear  to  be  mere  expressions  of  opinion.  The  only  actual  measurements, 
so  far  as  I  have  been  able  to  ascertain,  have  been  made  by  Herman,  who 
concluded  that  there  is  a  slight  spontaneous  dilatation  of  the  canal  during 
menstruation,  reaching  its  maximum  on  the  third  and  fourth  days.  This 
perhaps  explains  why  the  pain 
in  certain  cases  of  dysmenor- 
rhea is  apt  to  be  relieved  after 
the  first  day  or  two  of  the 
flow. 

Do  the  Fallopian  Tubes 
Participate ? —  A  question 
which  has  excited  much  dis- 
cussion, and  which  is  even  yet 
unsettled,  is  the  relation  of 
the  fallopian  tubes  to  men- 
struation. Do  they,  like  the 
body  of  the  uterus,  exhibit 
certain  characteristic  changes 
at  the  time  of  menstruation, 
and  do  they  help  in  the  elimi- 
nation of  the  menstrual  flow? 
These  questions  are  answered 
differently  by  different  ob- 
servers. There  are  some  who 
believe  that  the  tubes  play 
only  a  passive  role  in  men- 
struation. Others  again  con- 
sider the  tubal  mucosa  an  ac- 
tive factor  in  the  process, 
stating  that  it  exhibits  histological  alterations  just  as  does  the  endometrium, 
though  to  a  less  degree.  Unfortunately,  the  statements  of  many  authors  are 
not  of  scientific  value,  for  there  is  still  a  "  plentiful  lack  "  of  reliable  obser- 
vations on  the  subject.  Furthermore,  the  evidence  already  in  hand  is  quite 
conflicting,  so  there  is  need  of  much  more  work  upon  the  subject. 

Clinical  Evidence. —  A  large  number  of  cases  has  been  recorded  in 
support  of  the  theory  that  the  tubes  do  participate  in  the  menstrual  process. 
Bland's  case  was  one  in  which  there  was  a  discharge  of  blood  each  month 
from  a  sinus  resulting  from  an  old  operation.  It  was  later  found  that  the 
fimbriated  end  of  the  right  tube  had  become  adherent  to  the  scar,  so  that 
the  lumen  opened  directly  on  the  exterior.     Chapin  Minard's  case,  again, 


Fig.  2. —  Normal  Endometrium  (CuUen). 

Compare    epithelium,    glands    and    stroma   with 
those  in  Fig.  1. 


THE  SOURCE  OF  THE  MENSTRUAL  FLOW  21 

was  one  in  which  blood  was  seen  to  emerge  from  the  tubal  ostia  in  a  case 
of  inversion  of  the  uterus.  Other  cases  have  been  reported  by  Leopold, 
Sutton,  Hennig,  Landau  and  Rheinstein,  Courrant  and  others. 

In  the  majority  of  these  patients,  the  existence  of  tubal  menstruation  was 
determined  by  a  discharge  of  blood  at  the  menstrual  periods  from  sinuses 
communicating  with  the  lumen  of  the  tube ;  from  a  stump  of  the  tube  when 
this  had  healed  into  an  abdominal  cicatrix;  or  from  the  uterine  orifices  of 
the  tubes  when  these  were  rendered  visible  by  inversion  of  the  uterus.  The 
cases  belonging  to  the  first  two  groups  are  open  to  the  objection  that  there 
is  no  way  to  determine  whether  the  blood  has  really  been  given  off  by  the 
tubal  wall  or  whether  it  has  merely  entered  the  tube  from  the  uterine  cavity. 
The  difficulty  in  ascribing  the  blood  to  a  genuine  menstrual  function  of  the 
tube  is  increased  by  the  fact  that  we  are  not,  in  such  cases,  dealing  with 
normal  tubes,  but  with  tubes  which  in  most  instances  are  the  seat  of  pro- 
nounced pathological  alterations,  and  which  might  in  themselves  be  the 
cause  of  a  hemorrhagic  discharge,  especially  during  the  period  of  pelvic 
congestion  associated  with  menstruation. 

As  regards  the  cases  of  inversion  of  the  uterus  in  which  a  discharge  of 
blood  has  been  noted  from  the  exposed  uterine  orifices  of  the  tubes,  certainly 
such  profoundly  pathological  cases  as  these  can  not  be  utilized  to  prove  or 
disprove  the  participation  of  the  tube  in  the  process  of  normal  menstruation. 
The  circulatory  disturbances  which  must  inevitably  be  associated  with  such  a 
condition  as  long  standing  inversion  of  the  uterus  might  well  explain  the 
occurrence  of  a  bloody  discharge  from  the  tubes  at  the  time  of  menstruation, 
without  actually  stamping  it  as  a  genuine  menstrual  discharge. 

Histological  Evidence. —  As  Czyzewicz  has  pointed  out,  the  only 
reliable  method  of  determining  whether  or  not  the  tubes  take  part  in  the 
menstrual  process  is  by  means  of  microscopic  examination  of  normal  tubes 
removed  at  the  time  of  menstruation.  Such  specimens  may  be  obtained 
postmortem  from  women  who  have  died  suddenly  during  the  menstrual 
period  as  a  result  of  some  disease  which  in  itself  would  not  influence  men- 
struation. Or,  perhaps  better,  they  are  occasionally  obtainable  through 
operation  performed  at  the  menstrual  period  —  operations,  for  instance,  in 
which  the  sound  tubes  are  removed  with  the  uterus  in  the  course  of  a 
supravaginal  hysterectomy.  To  be  of  value  in  such  a  study  the  removed 
tubes  must  be  free  from  pathological  change,  they  must  not  be  injured  in 
removal,  and  they  must  be  placed  at  once  in  the  fixing  fluid.  In  addition, 
there  must  be  an  accurate  history  of  the  case,  especially  from  the  standpoint 
of  the  menstrual  dates  and  the  freedom  of  the  patient  from  any  condition, 
whether  general  or  local,  which  might  influence  the  periodicity  of  men- 
struation. 

Czyzewicz  describes  the  results  of  his  studies  in  six  cases  in  which  all 
these  requirements  seem  to  have  been  rigidly  observed.  His  technic  appears 
to  have  been  scrupulously  careful,  and  so  far  as  I  have  been  able  to  learn, 
his  study  is  the  only  one  to  which  no  exception  seems  possible  on  this  score. 


22  MENSTRUATION  AND  ITS  DISORDERS 

One  of  his  cases  was  operated  upon  on  the  first  day  of  menstruation,  one 
on  the  second,  and  the  others  on  the  fourth,  sixth,  seventh,  and  fourteenth 
days  after  the  onset  of  a  menstrual  period.  He  concludes  from  this  study 
that  typical  blood  elements  are  to  be  found  in  the  lumen  of  the  healthy  tube 
during  the  menstrual  period,  and  not  in  the  intermenstrual  period.  This, 
however,  is  not  equivalent  to  saying  that  the  blood  is  tubal  menstrual  blood, 
i.  e.,  that  it  has  found  its  way  out  from  the  tubal  vessels  by  rhexis  or  by 
diapedesis,  for  there  is  a  possibility  that  it  has  made  its  way  into  the  tube 
from  the  uterus,  or  even  from  the  abdominal  cavity. 

Czyzewicz  brings  forth  a  number  of  facts  in  support  of  the  view  that  the 
blood  does  not  spring  from  the  tubal  vessels.  In  the  study  of  a  large 
number  of  sections  he  failed  to  observe  any  actual  extravasation  of  blood 
from  a  ruptured  vessel  into  the  surrounding  tissue,  nor  could  he  establish 
any  direct  connection  between  the  red  blood  corpuscles  within  the  blood 
vessels  and  those  within  the  tubal  lumen.  As  additional  evidence  against 
the  theory  of  tubal  menstruation  may  be  mentioned  the  fact  that  the  epithe- 
lium in  tubes  removed  at  the  time  of  menstruation  shows  no  noteworthy 
changes.  There  is  an  absence  both  of  cellular  degenerative  changes  and 
also  of  any  such  heaping  up  of  the  epithelium  as  would  be  produced  by 
escaping  blood. 

As  a  result  of  his  investigations,  Czyzewicz  concludes  that  the  tubes  do 
not  participate  in  the  process  of  menstruation,  although  at  the  menstrual 
epochs  there  occurs  a  dilatation  of  the  tubal  blood  vessels  similar  to  that 
seen  throughout  the  generative  tract.  The  blood,  however,  does  not  leave 
the  blood  vessels.  The  blood  elements  that  may  be  found  in  the  tube  at  the 
time  of  menstruation  have  probably  been  forced  into  it  by  uterine  contrac- 
tions at  that  time.  Just  what  becomes  of  this  blood  is  not  easy  to  say. 
From  the  fact  that  phagocytes  are  not  found  in  the  tube  in  these  cases, 
Czyzewicz  believes  that  in  all  probability  the  blood  is  not  absorbed  in  the 
tube,  but  makes  its  way  back  into  the  uterine  cavity,  being  assisted  in  this 
movement  by  the  downward  propulsion  of  the  cilia. 

Most  of  the  cases  which  have  been  reported  as  examples  of  tubal  men- 
struation have  not  been  studied  with  sufficient  accuracy  or  thoroughness  to 
make  the  findings  of  much  value  in  this  regard.  A  fairly  thorough  reading 
of  the  literature  of  the  subject  leads  me  to  believe  that  there  is  not  at  the 
present  time  any  incontrovertible  evidence  of  active  participation  of  the 
tubes  in  the  menstrual  process.  In  a  number  of  laparotomies  performed 
during  menstruation,  in  which  the  tubes  were  carefully  examined  from  this 
standpoint,  I  have  never  been  able  to  detect  the  presence  of  blood  in  the 
tubes,  although  the  limitations  of  gross  observations  of  this  sort  are  obvious. 


THE  SOURCE  OF  THE  MENSTRUAL  FLOW  23 

III 

LITERATURE 

Bland.     Tubal  Menstruation.     Therap.  Gaz.,  1903,  27,  731. 

Bond.     Occurrence  of   Menstrual   Secretion  in  the   Fallopian  Tubes   in   the 

Human  Subject  and  its  Significance.     Brit.  M.  J.,  1898,  i,  1441. 
CouRRANT.     Tubenmenstruation.     Zentralb.  f.  Gyn.,  1899,  23,  13 19. 
CzYZEWicz.  •  Zur  Tubenmenstruation.     Arch.  f.  Gyn.,  1908,  85,  197. 
Delporte.     Recherches    sur    la    menstruation    tubaire.      Obstetrique,    Paris, 

1909,  2,  241. 
FiNDLEY.     Menstruating  Fallopian  Tube.     Amer.  J.  Obst.,  1903,  48,  515. 
Gebhard.     Die  Menstruation.     Veits  Handb.  d.  Gyn.,  1898,  3,  i ;    12. 
Herman.     On  the  Changes  of  Size  of  Cervical  Canal  during  Menstruation. 

Tr.  Obst.  Soc.  Lond.,  (1894)  1895,  36,  250. 
Holzbach.     Vergleichend-Anatomische    Untersuchungen     iiber    die    Tuben- 

brunst  und  die  Tubenmenstruation.     Zeitsch.  f.  Geb.  u.  Gyn.,  1908,  61, 

565- 
Landau  und  Rheinstein.     tjber  die  Menstruation,  etc.     Arch.  f.  Gyn.,  1892, 

421,  273. 
Leopold.     Untersuchungen  iiber  Menstruation  und  Ovulation.     Arch.  f.  Gyn., 

1885,  21,  347. 
Minard.     Does  the  Menstrual  Flow  Originate  in  the  Tubes?     The  Act  of 

Menstruation  Viewed  from  an  Inverted  Uterus.     Tr.  N.  Y.  Med.  Asso., 

1889,  47,  446. 
Montgomery.     Tubal  IMenstruation.     Therap.  Gaz.,  1904,  28,  522. 
Steinbuchel.     Zur  Frage  der  Tubenmenstruation.     Wien.  Klin.  Wchnsch., 

1905,  18,  1081. 
Sutton.     Menstruation  in  Monkeys.     Brit.  Gyn.  J.,  1887,  2,  285. 
Thomson.     Zur  Frage  der  Tubenmenstruation.     Zentralb.  f.  Gyn.,  1898,  22, 

1227. 
Thorn.     Zur  Frage  der  Tubenmenstruation.     Zentralb.  f.  Gyn.,  1904,  28,  971. 


CHAPTER  IV 

MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS 

HISTORICAL 

The  earliest  studies  on  the  anatomy  of  the  menstruating  uterus  were  made 
by  Kundrat  and  Engehnann,  whose  material  consisted  of  uteri  obtained  from 
cadavers.  Even  with  their  undeveloped  methods  these  workers  described 
certain  changes  as  characteristic  of  the  premenstrual  period  —  the  widening 
of  the  glands,  the  dilatation  of  the  blood  vessels,  and  the  round  cell  infiltra- 
tion of  the  interglandular  tissue.  Another  early  investigator  who  utilized 
the  uteri  of  cadavers  for  his  work  was  Williams,  nine  of  whose  cases  had 
died  of  acute  infectious  diseases,  thus  rendering  his  results  much  less  valu- 
able. Leopold,  on  the  other  hand,  selected  only  uteri  removed  from  wom.en 
who  had  died  very  suddenly,  and  whose  previous  menstrual  histories..showed 
no  abnormality.  He  found  that  shortly  before  the  onset  of  the  menstrual 
bleeding,  the  mucosa  swells,  partly  as  a  result  of  cell  growth,  and  partly  as 
a  result  of  edema.  The  superficial  capillaries  are  widened,  and  for  several 
days  there  is  an  escape  of  blood  into  the  surrounding  tissue.  As  a  result, 
the  epithelium  and  the  upper  cell  layers  are  pushed  off.  Leopold  did  not, 
however,  agree  with  Williams  in  the  view  that  the  destruction  of  the  mucosa 
is  complete.  Wyder  endeavored  to  settle  this  point  by  a  study  of  the  men- 
strual secretion  obtained  by  means  of  an  aspirating  syringe.  In  this  he 
found  desquamated  epithelial  and  stroma  cells,  although  he  was  later 
contradicted  in  this  respect  by  De  Sinety. 

It  was  Moricke  who  first  avoided  the  use  of  dead  material  by  studying 
the  scrapings  from  45  women  in  various  stages  of  the  menstrual  cycle.  He 
concluded  that  the  mucosa  remains  quite  intact  throughout  the  process. 
Perhaps  the  most  fruitful  early  work  on  the  subject,  however,  was  that  of 
Westphalen.  This  investigator  studied  curettings  and  freshly  extirpated 
uteri.  He  found  that  about  ten  days  before  the  beginning  of  menstruation 
there  begins  a  serous  or  sanguinoserous  edema  of  the  mucosa,  which  presses 
apart  the  meshes  of  the  stroma.  Marked  blood  vessel  dilatation  does  not 
occur  until  the  beginning  of  the  flow.  The  glands  increase  in  number, 
become  tortuous,  and  are  often  filled  with  secretion.  At  the  end  of  men- 
struation the  epithelium  constitutes  an  almost  complete  covering,  showing 
interruption  only  in  pathologic  conditions.  The  characteristic  regeneration 
begins  a  few  days  after  menstruation,  being  marked  by  the  appearance  of 
numerous  mitoses  which  during  menstruation  are  noted  only  sporadically. 

24 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS  25 

The  regeneration  involves  the  mucosa  as  a  whole,  the  stroma  as  well  as  the 
glands  and  the  epithelium.  Its  climax  is  reached  about  fourteen  or  fifteen 
days  after  the  beginning  of  the  bleeding.  Westphalen  speaks  of  the  time 
from  the  eighteenth  day  to  the  beginning  of  the  next  menstruation  as  the 
"  period  of  rest."  It  may  thus  be  seen  that,  in  large  measure,  Westphalen 
anticipated  our  modern  views  of  the  menstrual  anatomy  of  the  uterus,  as 
based  upon  the  later  work  of  Hitschmann  and  Adler. 

Even  such  a  brief  historical  resume  as  this  would  be  incomplete  without 
reference  to  the  work  of  Gebhard.  Up  to  quite  recent  years,  it  was  his 
description  of  the  anatomic  changes  in  connection  with  menstruation  which 
was  most  generally  accepted.  This  author  divides  the  process  of  menstrua- 
tion into  three  stages  :  First,  the  stage  of  premenstrual  congestion.  Before 
the  beginning  of  the  flow  there  occurs  a  marked  dilatation  of  the  capillaries 
and  a  widening  of  the  stromal  meshes,  which  are  filled  first  with  a  serous 
fluid,  then  wnth  blood  elements.  As  the  blood,  w^hich  breaks  through  the 
capillaries,  increases  in  amount,  it  is  driven  to  the  point  of  least  resistance, 
i.  e.,  the  surface.  The  lifting  of  the  epithelium  by  the  blood  forms  the  so- 
called  "  subepithelial  hematomata,"  Second,  the  stage  of  external  hemor- 
rhage. In  this  stage,  the  hematomata  open  and  discharge  their  blood  on 
the  surface,  i.  e.,  into  the  uterine  cavity.  Third,  the  stage  of  postmenstrual 
regeneration.  The  disappearance  of  the  swelling  is  looked  upon  as  due  to 
the  bleeding.  The  blood  in  the  tissues  which  has  not  reached  the  surface 
disappears  gradually  through  resorption,  or  is  converted  to  a  yellowish  or 
brownish  pigment  which  withstands  absorption  for  a  considerable  while. 
Other  valuable  investigations  of  the  menstrual  histology  of  the  uterus  have 
been  made  by  Mandl,  von  Kahlden,  Lohlein,  Van  Meerdervoort,  Jakobs, 
Herman  and  Wendeler. 

MACROSCOPIC  CHANGES  IN  UTERUS  AT  MENSTRUATION 

Perhaps  the  most  conspicuous  macroscopic  change  occurring  during  men- 
struation is  the  pelvic  hyperemia  so  characteristic  of  the  process.  The 
pelvic  vessels,  especially  those  of  the  uterus  and  adnexa,  are  engorged  with 
blood.  Operations  performed  at  this  time  are  usually  attended  with  much 
more  hemorrhage  than  at  other  times.  The  uterus,  as  a  result  of  this  influx 
of  blood,  becomes  slightly  enlarged  bluish  red  in  color,  and  rather  soft  in 
consistency. 

THE  ENDOMETRIUM 

Macroscopic  Changes. — Aside  from  the  con^gestion  of  the  endometrium, 
with  a  consequent  reddish,  engorged  appearance,  the  most  conspicuous 
gross  change  is  in  its  thickness.  According  to  Doderlein  the  greatest  thick- 
ness which  is  noted  physiologically,  i.  e.,  in  the  absence  of  pathological 
alteration,  is  about  7  mm.,  although  Schroder  has  found  it  in  some  cases 
to  reach  the  thickness  of  8  mm. 


26  MENSTRUATION  AND  ITS  DISORDERS 

The  portion  of  the  endometrium  which  becomes  thus  thickened  is  the 
so-called  superficial  or  "  functional  "  layer.  The  compact  layer,  or,  to  use 
the  term  employed  by  Schroder,  the  basal  layer,  is  of  practically  constant 
thickness,  usually  0.7  to  1.2  mm.  The  cause  of  the  increase  in  the  thickness 
of  the  endometrium  is  threefold :  ( i )  the  increase  in  the  size  of  the  epithelial 
cells,  owing  to  the  secretory  activity;  (2)  the  increased  amount  of  blood  in 
the  blood  vessels;  (3)  the  greater  or  less  degree  of  edema  always  found 
just  before  menstruation. 

Histological  Changes. — ^  Within  recent  years  considerable  light  has 
been  thrown  upon  the  study  of  menstruation  by  an  increased  knowledge  con- 
cerning the  histological  changes  which  occur  in  the  endometrium  during  the 
various  phases  of  the  menstrual  cycle.  In  order  to  appreciate  the  changes 
which  recent  investigations  have  brought  about  in  our  conception  of  the- 
structure  of  the  normal  endometrium  and  of  its  changes  at  various  periods, 
one  need  only  read  the  descriptions  to  be  found  in  the  older  text  books  of 
gynecology  and  anatomy. 

Structure  of  Normal  Endometrium. —  In  the  usually  accepted  sense, 
as  already  stated,  the  endometrium  is  the  corporeal  portion  of  the  uterine 
mucosa,  i.  e.,  the  portion  above  the  level  of  the  internal  os.  It  is  best 
described  as  consisting  of  a  surface  epithelium,  glandular  elements,  and 
an  interglandular  tissue  known  as  the  stroma. 

The  epithelium  is  of  the  ciliated  columnar  variety,  differing  from  that 
found  in  the  cervix  in  that  the  cells  are  not  so  tall  and  not  so  slender; 
that  the  nuclei  take  a  paler  stain,  and  are  situated  near  the  center  of  the 
cells  instead  of  near  the  basement  membrane ;  and  that  the  protoplasm  takes 
an  acid  stain,  while  that  in  the  cervix  not  uncommonly  takes  an  alkaline 
stain  on  account  of  the  excessive  amount  of  mucus  which  it  contains.  (See 
Figs.  I  and  2) 

The  glands  are  of  the  simple  or  branched  tubular  variety,  and  are  lined  by 
epithelium  continuous  with  and  similar  to  that  on  the  surface.  The  glands 
extend  down  to  the  muscular  coat  of  the  uterus,  and  not  infrequently  pene- 
trate the  muscle  to  some  extent,  carrying  with  them  an  enveloping  mantle 
of  stroma. 

According  to  most  authors  the  stroma  is  made  up  of  a  delicate  reticular 
network  of  fibrillar  connective  tissue,  containing  in  its  meshes  large  numbers 
of  oval  or  spindle  cells.  At  the  present  time  there  is  no  unanimity  of  opinion 
as  to  the  exact  nature  of  the  stromal  tissue.  Nagel  and  Waldeyer  believed 
it  to  be  of  a  lymphatic  type  and  compared  it  to  the  stroma  of  the  intestinal 
mucosa;  Leopold  regarded  it  as  a  spread  out  lymphatic  gland  (lymph- 
driisenMche),  while  Johnstone  considered  it  to  be  of  an  adenoid  type. 
Most  authorities  accept  the  view  of  Minot,  that  the  stroma  is  merely  a  form 
of  embryonic  connective  tissue,  and  this  is  probably  correct. 

Modern  Views  as  to  Menstrual  Histology  of  the  Endometrium. — 
From  a  physiologic  point  of  view  the  endometrium  bears  an  important 
relation,  whether  active  or  passive,  to  the  function  of  menstruation,  and  it 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS 


27 


would  be  interesting,  if  space  permitted,  to  trace  the  various  views  which 
have  at  different  times  been  held  as  to  the  changes  in  the  endometrium  at  the 
time  of  menstruation.  Unfortunately,  up  to  recent  years  the  extent  of 
these  changes  has  been  gauged  largely  by  the  comparative  study  of  men- 
struating and  non-menstruating  uteri,  and  there  has  been  no  systematic 
effort  to  study  the  histologic  structure  of  the  endometrium  from  the  begin- 


PlG.  3. —  The  ENDOMETRItIM  IN"  THE  POSTMENSTRUAL  STAGE. 

Note  especially  the  straight,  narrow,  collapsed  glands. 

ning  to  the  end  of  the  menstrual  cycle.  In  1908,  however,  an  important 
contribution  to  our  knowledge  of  this  subject  was  made  by  Hitschmann 
and  Adler,  whose  work  has  revolutionized  our  former  ideas  of  the  histology 
and  pathology  of  the  endometrium.  These  observers,  after  a  painstaking 
study  of  the  uterine  mucosa  from  58  women  at  various  periods  of  the  men- 
strual cycle,  were  able  to  demonstrate  quite  clearly  that  the  uterine  mucosa 
undergoes  a  cyclical  histological  change  which  corresponds  to  the  clinical 


28 


MENSTRUATION  AND  ITS  DISORDERS 


cycle  of  menstruation.     This  developmental  cycle  in  the  endometrium  they 
divide  into  four  stages,  as  follows : 


Fig.  4. —  The  E^rDOMETRIUM  in  the  Interval  Stage. 

The  glands  are  undergoing  a  gradual  hypertrophy,  being  now  moderately  tortuous.    The 
stroma  is  still  rather  dense  and  compact. 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS 


29 


The   P ost menstrual 
Stage,  embracing  the 
few  days  immediately 
following     menstrua- 
tion.    During  the  lat- 
ter It  seems  as  if  the 
ium    empties 
were,    so 
the  post- 
period    its 
narrow, 
|vi^    collapsed,  and  straight, 
while    the    stroma    is 
rather  firm  and  com- 
pact (Fig.  3). 

The  Interval  Stage 


f^§,  scribed.  During  this 
period  the  endome- 
trium is  undergoing  a 
steady  but  gradual  de- 
velopment, the  glands 
becoming  fuller  and 
exhibiting  gradually 
increasing  convolu- 
tion. The  stroma  is 
still  quite  compact  in 
appearance  (Fig.  4). 
The  Premenstrual 
Stage  begins  from  a 
few  days  to  a  week  or 
more  before  the  next 
menstruation.  At  this 
time,  according  to 
Hitschmann  and  Ad- 
ler,  there  is  a  sudden 
Fig.  5. —  The  Endometrium  in  the  Premenstrual  Phase,  increase  in  the  hyper- 
The  glands  are  markedly  hypertrophied,  so  that  on  longi-  trophic  development 
tudinal  section  they  are  saAv-like  in  appearance,  while  on  cross       ,      .  ,  . 

section  they  show  a  characteristic  scalloping.  The  epithelium  ^t  the  endometrium', 
gives  evidence  of  secretory  activity,  being  low,  mucoid  and  'pj^g  lumina  of  the 
"frayed."     The  typical  decidua-like  appearance  of  the  stroma      1^1  1 

is  well  shown  in  the  superficial  layer  of  the  endometrium.  glands    become    mucn 


30 


MENSTRUATION  AND  ITS  DISORDERS 


increased,  presenting  a 
cbaracteristic  scallop- 
ing on  cross  section, 
while  in  longitudinal 
section  they  exhibit  a 
dentate  appearance 
{sagcfonnigc  drilscn ) . 
In  very  marked  cases 
there  is  a  strong  re- 
semblance to  the 
glands  of  early  preg- 
nancy. The  epithe- 
lium undergoes  a 
mucoid  change,  often 
appearing  low  and 
shreddy.  The  stroma 
cells  participate  in  the 
general  process  of  de- 
velopment, and  in  ex- 
aggerated instances 
may  shov^  such  a  pro- 
toplasmic increase  as 
to  simulate  very 
closely  ordinary  de- 
cidual cells.  More  fre- 
quently, however, 
there  is  only  a  sugges- 
tion of  this  change, 
the  cells  being  of  a 
transitional  type 
{decidua-dhnliche  zel- 
len  or  ilhergangszel- 
len).     (Fig.  5) 

The  Menstrual 
Stage,  corresponding 
to  the  actual  existence 
of  menstruation,  is 
characterized  micro- 
scopically by  appear- 
ances which  are  to  be 
looked  upon  as  a  tran- 
sition from  those  of 
the  premenstrual 

period  to  those  of  the 
postmenstrual  phase. 
In  addition  to  the 
vascular      phenomena 


Fig.  6. —  Endometrium  on  Second  Day  of  Menstruation. 

Some  of  the  glands  are  still  large  and  hypertrophied;  others 
have  become  small  and  collapsed,  as  in  the  postmenstrual  stage. 
There  is  marked  injection  of  the  small  capillaries  and  venules, 
while  lacunae  of  blood  are  often  seen  in  the  tissues.  As  will  be 
seen  from  this  section,  extensive  loss  of  the  epithelium  is  not  3, 
characteristic  feature  of  menstruation. 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS  31 

characteristic  of  this  stage,  one  finds  usuahy  that  some  of  the  glands  are 
still  very  hypertrophic,  while  others  already  show  the  collapse  characteristic 
of  the  postmenstrual  stage.  A  similar  transition  is  noted  in  the  stromal 
tissue.     (Fig.  6) 

In  the  eleven  years  which  have  elapsed  since  the  puhlication  of  the  work 
of  Hitschmann  and  Adlcr,  many  articles  have  appeared  in  confirmation  of 
their  results,  and  a  few  in  which  a  greater  or  less  degree  of  contradiction  is 
expressed.  Among  the  more  important  of  the  latter  may  be  mentioned 
those  of  Henkel,  and  Keller  and  Schickele.  Both  of  these,  however, 
have  been  very  adequately  answered  in  the  recent  exhaustive  review  of 
the  subject  by  Hitschmann  and  Adler.  At  any  rate,  the  weight  of 
evidence  at  the  present  day  is  overwhelmingly  in  favor  of  the  general  cor- 
rectness of  their  teaching,  although  on  certain  details  there  is  still  room  for 
discussion. 

It  is  an  interesting  commentary  on  the  rapidity  with  which  our  knowledge 
of  such  subjects  is  changing  to  call  attention  to  the  fact  that  already  a 
revision  of  this  description  is  offered  by  Schroder,  who  has  done  such  excel- 
lent work  along  these  lines.  This  author  believes  that  the  entire  functional 
layer  of  the  endometrium  is  lost  at  each  menstrual  period,  being  regenerated 
from  the  glands  of  the  basal  layer.  The  period  of  desquamation  and  regen- 
eration, according  to  Schroder,  embraces  a  period  extending  from  the  first 
to  the  fifth  days  of  the  menstrual  cycle,  counting  from  the  day  of  menstrual 
onset.  Following  this  comes  the  proliferative  phase,  during  which  the 
glands  exhibit  progressively  increasing  proliferative  changes,  although  no 
sign^  of  secretory  activity  are  evident  during  this  period.  The  proliferative 
changes  in  the  glands,  Schroder  explains,  are  due  to  the  maturing  follicle. 
Ovulation  takes  place  about  the  fifteenth  day  of  the  cycle,  and  the  corpus 
luteum  thus  formed  is  the  cause  of  the  secretory  activity  of  the  gland 
epithelium,  reaching  its  climax  just  before  menstruation. 

Schroder's  division  of  the  menstrual  cycle,  therefore,  is  into  three  stages : 
(i)  the  stage  of  desquamation  and  degeneration,  extending  from  the  first 
to  the  fifth  days  of  the  cycle;  (2)  the  proliferative  stage,  from  the  fifth  to 
the  fifteenth  days;  and  (3)  the  secretory  stage,  from  the  fifteenth  to  the 
twenty-eighth  days.  The  work  of  Schroder,  if  confirmed  by  subsequent 
studies,  will  mark  a  big  step  toward  the  study  of  the  true  relation  of  men- 
struation and  ovulation,  as  will  be  discussed  in  a  subsequent  chapter. 

Changes  in  Epithelium  during  Menstrual  Cycle. —  An  Important 
factor  in  the  structure  of  the  endometrium  is,  of  course,  the  epithelium, 
and  upon  its  alterations  are  largely  dependent  the  variations  in  the  appear- 
ance of  the  endometrium  at  different  stages  of  the  menstrual  cycle.  This  is 
especially  true  of  the  differences  in  the  appearance  of  the  glands  at  different 
phases  of  the  cycle,  and  also  of  the  varying  thickness  of  the  uterine  mucosa. 

It  has  been  asserted  by  Theilhaber  and  others  that  the  epithelial  cells  of 
the  corpus  uteri,  like  those  of  the  cervix,  functionate  continually ;  but  this 
is  denied  by  Schroder,  who  emphasizes  that  secretory  activity  Is  character- 


32  MENSTRUATION  AND  ITS  DISORDERS 

istic  of  the  premenstrual  and  the  latter  portion  of  the  interval  periods  —  in 
other  words,  that  it  begins  only  after  the  formation  of  the  corpus  luteum, 
upon  which  it  is  dependent.      (See  Chapter  V.) 

In  the  postmenstrual  period  the  epithelium,  some  of  which  is  lost  during 


^ti^^^^i^^        c^==::^^======^=:::>    ,       q 


iJ.«52S3  ®   IS 


ii' 


Fig.  7. —  The  Characteristic  Changes  in  the  Uterine  Epithelium,  Glands  and 
Stroma  at  the  Various  Phases  of  the  Menstrual  Cycle. 

1. —  The  postmenstrual  stage;  (a)  epithelium,  (b)  gland  in  longitudinal  section,  (bi) 
gland  in  cross  section,  (c)  stroma. 

2. —  The  interval  stage;  (a)  epithelium,  (b)  gland  in  longitudinal  section,  (bi)  gland  in 
cross  section,  (c)  stroma. 

3. —  The  premenstrual  stage;  (a)  epithelium,  (b)  gland  in  longitudinal  section,  (b^)  gland 
in  cross  section,  (c)  stroma. 

N.  B. —  The  menstrual  stage  is  not  illustrated,  as  it  represents  a  transition  from  (3) 
to  (1). 


menstruation,  is  low  and  cuboidal,  slowly  becoming-  higher  later  in  the 
interval.  During  the  premenstrual  period  the  cells  are  bloated  and  in  many 
cases  granular  or  rather  shreddy,  as  a  result  of  their  active  secretory 
function  (Fig.  7). 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS  33 

Changes  in  Uterine  Glands  during  Menstrual  Cycle. —  The  glan- 
dular changes  are  much  more  striking  and  much  more  constant  than  those 
noted  in  the  stroma,  and  therefore  constitute  the  more  reliable  and  con- 
venient criterion  of  the  degree  of  menstrual  reaction  in  the  endometrium. 
In  only  a  comparatively  small  proportion  of  the  cases  is  there  such  a  striking 
overgrowth  of  the  stromal  cells  that  they  are  at  all  likely  to  be  mistaken  for 
genuine  decidual  cells.  On  the  other  hand,  a  greater  or  less  degree  of 
gland  hypertrophy,  easily  appreciable  on  microscopic  examination,  is  quite 
constant.  It  must  not  be  assumed  that  the  glandular  phenomena  are  pri- 
mary in  character.  Like  other  mucous  .glands,  the  uterine  glands  are 
merely  reduplications  of  the  mucous  membrane,  the  evident  purpose  of 
which  is  to  increase  the  secreting  surface.  When  the  glands  show  dilata- 
tion of  the  lumina  and  exaggerated  infoldings,  as  they  do  in  connection 
with  thie  premenstrual  hypertrophy,  it  is  because  the  individual  cells  are 
swollen  and  overgrown.  Room  is  made  for  these  enlarging  cells  by  increas- 
ing convolution  of  the  glands. 

The  old  rule  of  Gebhard  that  the  glands  are  to  be  considered  abnormal 
if  the  distance  between  them  is  less  than  four  or  five  times  the  diameter  of 
the  glands,  has  long  since  been  shown  to  be  incorrect,  for  there  are  wide 
normal  variations  in  different  mucosae  in  this  respect.  Moreover,  in  the 
examination  of  curettings,  the  microscopic  appearance  as  to  this  point  varies 
in  different  portions  of  the  endometrium  and  even  more  at  different  depths 
of  the  mucosa.  When  one  considers  the  individual  variations  in  different 
women,  with  regard  to  the  duration  and  amount  of  the  menstrual  flow,  it  is 
not  surprising  that  there  should  also  be  a  wide  variation  in  the  degree  of 
gland  changes  exhibited  at  the  premenstrual  period.  As  Hartje  has  pointed 
out,  there  is  a  gradual  progression  from  the  straight,  collapsed  gland  of 
the  postmenstrual  period  to  the  gland  at  the  height  of  premenstrual  develop- 
ment —  the  gland  with  papillary  ingrowths  and  perhaps  secondary  alveoli. 
In  the  more  marked  cases  the  glands  are  very  much  widened.  The  stroma 
is  diminished,  so  that  the  glands  are  almost  in  contact  and  the  epithelium  is 
swollen  with  secretion.  Many  of  the  glands  show  well  marked  papillary 
projections  into  the  lumen,  or  in  the  less  marked  cases  take  on  a  saw-like 
appearance  (sdgefdrmigedriisen).  (Fig.  5.)  Such  glands  as  these  were 
at  one  time  considered  pathognomonic  of  pregnancy  (Opitz),  although 
recent  investigations  have  shown  clearly  that  this  is  not  the  case.  Schwab, 
for  example,  in  his  examination  of  a  series  of  41  curettings,  found  Opitz's 
"  pregnancy  "  glands  in  5  women,  and  of  these  5  only  i  was  pregnant,  the 
other  4,  however,  showing  a  definite  relation  to  the  menstrual  process  —  3 
being  premenstrual  and  i  menstrual.  I  have  frequently  seen  such  glands 
in  the  premenstrual  mucous  membranes  of  non-pregnant  women.  Accord- 
ing to  Hartje,  the  maximum  gland  changes,  with  papillary  formations,  etc., 
are  seen  in  about  one  third  of  premenstrual  cases,  the  remainder  showing 
merely  the  tooth-like  or  saw-like  appearance  characteristic  of  less  advanced 
stages. 


34  MENSTRUATION  AND  ITS  DISORDERS 

Stromal  Changes  during  Menstrual  Cycle. —  As  already  stated,  the 
stromal  changes  are  usually  less  conspicuous  and  less  constant  than  those 
seen  in  the  glands.  In  a  series  of  50  cases,  which  I  studied,  there  were  4 
in  which  decidual  modifications  of  the  stroma  cells  were  sufficiently  marked 
to  be  conspicuous.  All  of  these  occurred  among  a  group  of  13  cases  in 
which  the  glands  exhibited  premenstrual  changes.  Among  these,  however, 
was  I  in  which  operation  was  done  10  days  after  menstruation,  so  from  this, 
it  would  seem  that  other  influences  than  normal  menstruation  may  perhaps 
be  capable  of  producing  a  decidual  modification  of  the  stromal  cells.  At 
one  time  the  decidual  cell  was  looked  upon  as  practically  pathognomonic  of 
pregnancy.  A  number  of  observers,  notably  Lofquist,  have  found  decidual 
cells  present  to  a  more  or  less  marked  degree  independent  of  pregnancy, 
in  association  with  such  conditions  as  adnexal  diseases,  tumors,  displace- 
ments, etc.  In  most  cases,  unfortunately,  the  value  of  such  observations  is 
lessened  by  the  failure  of  the  authors  to  recognize  the  possible  influence  of 
menstruation  in  producing  a  decidual  modification  of  the  stroma  cells. 

In  a  few  of  the  more  recent  reports,  however,  such  as  that  of  Goodall, 
this  possibility  seems  to  have  been  borne  in  mind,  and  it  is  quite  probable 
that  the  stromal  changes,  as  well  as  the  gland  changes,  may  be  brought 
about  by  various  conditions  other  than  normal  menstruation,  such  as  inflam- 
matory diseases,  tumors,  displacements,  and  tuberculosis.  This  would 
merely  be  in  keeping  with  the  biologic  law  that  the  natural  result  of  over- 
nutrition  of  tissue  is  overgrowth.  As  with  the  decidual  cells  of  pregnancy, 
the  decidua-like  cells  of  menstruation  are  seen  most  conspicuously  in  the 
superficial  compact  layer  of  the  endometrium.  (Figs.  5  and  7.)  They  are 
much  less  characteristic  of  the  premenstrual  period  than  are  the  glandular 
phenomena.  Like  the  latter,  they  reach  their  highest  development  jiist 
before  the  beginning  of  the  menstrual  period. 

According  to  Hartje,  the  decidual-like  cells  {decidua-dhnliche  zellen')  are 
seen  in  about  one  third  of  the  premenstrual  cases.  All  stages  of  develop- 
ment are  seen,  from  the  normal  stroma  cells,  with  no  protoplasm,  to  the 
typical  decidual  cell  with  its  large  oval  nucleus  surrounded  by  a  well  marked 
protoplasmic  area.  Those  who  maintain  that  there  is  an  essential  difference 
between  the  decidua-like  cells  of  menstruation,  and  the  genuine  decidual 
cells  of  pregnancy,  have  not  been  able  to  define  wherein  the  difference  lies. 
The  conclusion  is  forced  upon  us  that  the  modified  stroma  cells  of  men- 
struation ( ilbergangsncUcn)  are  simply  different  stages  in  a  series  in  which 
the  true  decidual  cell  represents  the  maximum  development.  As  Lofquist 
said,  "All  the  commonly  observed  changes  in  the  endometrium  may  be 
regarded  as  the  response  of  the  tissue  to  stimulation  —  as  varying  degrees 
of  what  has  been  called  the  decidual  reaction." 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS  35 

VASCULAR  CHANGES  OF  MENSTRUATION 

So  far  I  have  said  nothing*  as  to  the  vascular  changes  in  the  uterus  itself. 
The  blood  vessels  of  the  uterus  are  enlarged  and  engorged  with  blood,  and, 
according  to  the  observation  of  Willey  and  others,  many  of  the  capillary 
fissures  observed  in  the  endometrium  during  menstruation  disappear  in  the 
intermenstrual  period.  Inasmuch  as  menstruation  is  a  vasomotor  phe- 
nomenon, the  study  of  the  circulatory  changes  in  the  uterus  is  obviously  of 
fundamental  importance.  Up  to  a  few  years  ago  the  attention  of  investi- 
gators was  directed  mainly  to  a  study  of  the  blood  supply  of  the  endome- 
trium. More  recently,  however,  the  muscular  wall  of  the  uterus  has 
received  much  attention  from. this  standpoint. 

There  are  many  now  who  believe  that  the  endometrium  plays  a  purely 
passive  part  in  the  monthly  cycle,  and  some  who  look  upon  the  menstrual 
bleeding  as  dependent  upon  changes  in  the  muscular  wall  rather  than  in  the 
endometrium  itself.  Whatever  the  truth  may  be  as  regards  this  process, 
at  the  time  of  the  menses  and  just  preceding  it,  the  blood  vessels  of  the 
endometrium  are  overdistended  with  blood  and,  as  already  stated,  many 
new  capillary  fissures  become  apparent.  It  is  probable  that  these  are  not 
newly  formed,  but  that  they  become  visible  only  when  distended  with  blood 
at  the  time  of  menstruation.  "  The  endometrium  is  richly  supplied  with 
arteries  derived  from  the  parenchyma.  These  run  along  the  utricular 
glands  in  such  a  manner  as  to  completely  encircle  them  by  capillaries.  They 
form  immediately  under  the  epithelial  coat  an  irregular  network  of  wide 
vessels,  from  which  the  valveless  veins  originate,  to  collect  in  turn  in  the 
uterine  and  pampiniform  plexuses."  ( Spiegelberg. )  A  great  many  years 
ago  Tarnier  stated  that  the  menstrual  hemorrhage  is  venous  in  its  origin, 
basing  this  statement  upon  the  fact  that  the  small  blood  vessels  of  the 
endometrium  become  very  much  enlarged  during  pregnancy,  and  that  they 
are  then  seen  to  belong  to  the  venous  system.  He  admits,  however,  that 
there  may  be  a  certain  amount  of  arterial  blood  mixed  in  with  the  venous. 
This  old  view  of  Tarnier  is  interesting  in  the  light  of  the  recent  work  of 
Sampson.  In  the  course  of  a  painstaking  study  upon  the  blood  supply  of 
uterine  myomata,  carried  out  by  the  injection  method,  he  concludes  that  the 
menstrual  bleeding  has  its  origin  in  the  veins. 

The  question  of  just  how  the  blood  escapes  from  the  blood  vessels  to  the 
surface  of  the  epithelium  has  been  discussed  for  many  years.  Gebhard's  old 
theory  of  menstruation  assumed  that  the  blood  made  its  way  out  largely  by 
rhexis,  being  then  collected  under  the  epithelium  in  the  form  of  what  he 
called  "  subepithelial  hematomata."  These  tiny  collections  of  blood,  he 
stated,  lift  up  the  epithelial  cells,  which  degenerate  and  thus  allow  the 
blood  to  break  through  to  the  surface.  This  description  of  the  menstrual 
process  is  similar  to  that  given  by  Heape  of  the  corresponding  process  in 
monkeys.  Most  investigators,  however,  believe  that  the  blood  passes 
through  the  blood  vessel  walls  by  diapedesis  and  that  there  is  no  loss  of 


36  MENSTRUATION  AND  ITS  DISORDERS 

integrity  on  the  part  of  the  blood  vessel  walls.  Specimens  of  the  endome- 
trium removed  at  the  time  of  menstruation,  of  which  I  have  studied  a 
number,  show  a  large  quantity  of  blood  within  the  blood  vessels  and  usually 
a  large  number  of  red  blood  corpuscles  outside  of  the  blood  vessel  walls  and 
in  the  stroma.  (Fig.  6.)  I  have  never,  however,  seen  any  indication  of 
rupture  of  the  blood  vessel  wall.  While  the  question,  therefore,  has  not 
been  definitely  settled,  it  would  seem  that  the  weight  of  evidence  is  in  favor 
of  the  view  that  diapedesis  is  a  much  more  important  factor  than  rhexis  in 
determining  the  passage  of  the  blood  elements  from  within,  the  blood 
vessel  walls. 

IS  UTERINE  MUCOSA  LOST  AT  MENSTRUATION? 

Another  question  which  has  received  a  great  deal  of  study,  and  which 
has  been  extensively  discussed  for  many  years,  is  whether  or  not  there  is 
any  loss  of  epithelial  tissue  during  menstruation  —  whether,  in  other  words, 
the  endometrium  is  wholly  or  partly  cast  off  at  the  monthly  periods.  Some 
of  the  older  views  on  this  question  have  already  been  epitomized  in  the 
opening  paragraph  of  this  chapter.  As  already  stated,  the  menstrual  dis- 
charge, in  addition  to  blood,  mucus  and  leukocytes,  is  commonly  stated  to 
contain  epithelial  cells  from  the  various  portions  of  the  generative  tract. 

In  support  of  the  view  that  only  a  small  proportion  of  uterine  epithelium 
is  lost  at  the  time  of  menstruation,  may  be  mentioned  the  observations  of 
Moricke,  Strassman,  Findley,  Cullen,  AVilliams,  Gebhard,  Mandl,  Leopold 
and  Meerdervoort.  These  authors  consider  that  any  loss  of  epithelium  which 
may  occur  is  more  or  less  incidental  and  that  it  is  not  essential  to  the 
occurrence  of  the  process. 

Opposed  to  this,  is  the  view  that  an  extensive  loss  of  epithelium  is  a 
characteristic  of  the  menstrual  phenomenon,  and  that  this  shedding  is  to  be 
looked  upon  as  a  purely  mechanical  process.  Among  the  supporters  of  this 
theory  may  be  mentioned  Engelmann,  Kundrat,  Marshall,  Minot  and  others. 
According  to  Heape,  a  complete  shedding  of  the  uterine  mucosa  is  the  rule 
in  the  lower  animals  which  menstruate,  more  particularly  the  monkey.  It 
is  interesting  to  note,  also,  that  Heape  considers  that  the  stromal  cells  left 
behind  are  capable  of  metaplasia  into  a  new  epithelial  lining.  If  this  be 
true,  it  would  offer  an  explanation  of  the  remarkable  rapidity  with  which 
the  epithelium  regenerates  after  each  period.  There  has  been  no  evidence, 
however,  of  similar  metaplastic  phenomena  in  the  human  uterus,  and,  as  a 
matter  of  fact,  the  conception  is  rather  incompatible  with  our  notions  of  the 
histological  separateness  of  epithelium  and  connective  tissue. 

Reference  has  already  been  made  to  the  work  of  Schroder,  who  asserts 
that  with  each  menstrual  period  there  is  a  complete  loss  of  the  superficial  or 
functional  layer  of  the  endometrium,  followed  by  regeneration  from  the 
gland  rests  of  the  basal  layer,  which  remains  intact.  The  evidence  for  this 
view,  however,  is  not  conclusive. 


MENSTRUAL  CYCLIC  CHANGES  IN  THE  UTERUS  37 

From  an  examination  of  many  hundreds  of  endometriums,  including  a 
number  removed  during  menstruation,  it  seems  to  me  that  Schroder's  view 
is  an  extreme  one.  I  believe  that  in  a  very  small  number  of  instances  the 
superficial  layer  of  the  mucosa  may  be  cast  off,  perhaps  in  its  entirety,  con- 
stituting one  type  of  menstrual  cast,  and  associated  clinically  with  the  so- 
called  membranous  dysmenorrhea.  On  the  other  hand,  in  by  far  the  largest 
number  of, cases,  no  epithelial  loss  can  be  determined,  other  than  perhaps  that 
occasioned  by  the  lifting  up  of  small  strips  by  little  collections  of  blood 
which  are  making  their  escape  into  the  uterine  cavity.  (Fig.  6.)  No  doubt 
there  are  intermediate  grades  of  tissue  loss  between  these  extremes. 

In  other  words,  no  general  law  can  be  laid  down  as  applicable  to  all 
women  in  this  regard.  In  perhaps  the  majority,  the  loss  of  tissue  at  men- 
struation is  very  slight  and  only  incidental.  In  a  smaller  number  it  may  be 
larger,  so  that  shreds  or  flakes  of  epithelium  may  be  passed  from  the  uterus 
with  the  menstrual  discharge,  while  in  the  extreme  cases,  the  superficial  layer 
of  the  endometrium  may  be  passed  off  as  a  menstrual  cast.  The  entire 
question,  however,  is  still  a  debatable  one,  and  there  is  need  of  further  work 
along  this  line. 


IV 
LITERATURE 

AscHHEiM.     Zur  Histologie  der  Uterusschleimhaut.     Zeitsch.   f.     Geb.     u. 

Gyn.,  1915,  77,  485- 
Brennicke.     Zur  Atiologie  der  Endometritis  Fungosa,  etc.     Arch.   f.  Gyn., 

1882,  20,  455. 
Franz.     Ein  Beitrag  zur  Kenntnis  der  Endometritis  Hyperplastica  Ovarialis. 

Arch.  f.  Gyn.,  1898,  56,  363. 
Gebhard.     Die  Menstruation.     Veits  Handb.  d.  Gyn.,  1898,  v.  3,  i. 
GooDALL.     Decidual  Changes  in  the  Endometrium  Due  to  Causes  other  than 

Pregnancy.     Amer.  J.  Obst.,  1909,  59,  389. 
Hartje.     Ueber  die  Beziehungen  der  Sogenannten  Papillaren  Uterindrusen 

zu  den  Einzelen  Menstruationsphasen.     Monats.  f.  Geb.  u.  Gyn.,  1907, 

31,  14^5- 
Henkel.    Klinische  und  Anatomische  Untersuchungen  iiber  die  Endometritis. 

Zentralb.  f.  Gyn.,  1909,  33,  201. 
HiTSCHMANN  und  Adler.     Der  Bau  der  Uterusschleimhaut  des  Geschlechts- 

reifen    Weibes    mit    besonderer    Beriicksichtigung    der    Menstruation. 

Monats.  f.  Geb.  u.  Gyn.,  1908,  27,  i. 
IwASE.     Ueber  die  Cyklische  Umwandlung  der  Uterusschleimhaut.     Ztschr.  f. 

Geb.  u.  Gyn.,  1908,  63,  614. 
Johnstone.     The  Menstrual  Organ.     Brit.  Gyn.  J.,  1886,  2,  292. 
Jolly.      Atlas    zur    Mikroskopischen    Diagnostik    der    Gynakologie.      Berlin 

und  Wien,  1910. 


38  MENSTRUATION  AND  ITS  DISORDERS 

VON  Kahlden.     Ueber  das  Verhalten  der  Uterusschl'eimhaut  waiirend  una 

nach  der  Menstruation.    Hegar's  Festschrift,  Beitrage  zur  Geb.  u.  Gyn. 

1889,  p.  107. 
KuNDRAT   und   Engelmann.     Untersuchungen   liber    die   Uterusschleimhaut. 

]\Ied.  Jahrbiicher,  Wien,  1873. 
Landau   und    Rheinstein.      Ueber   das   Verhalten    der   Verschlossene    und 

Missgebildeten  Genitahen  und  iiber  die  Tubenmenstruation.     Arch.   f. 

Gyn.,  1892,  42,  273. 
Leopold.     Studien  iiber  die  Uterusschleimhaut.     Berlin,  1878. 

Untersuchungen  iiber  Menstruation  und  Ovulation.     Arch.  f.  Gyn.,  1885, 

21,  347- 
LoFQUiST.     Zur  Kenntnis  der  Pathologischen  Anatomie  des  Endometriums. 

Zentralb.  f.  Gyn.,  1901,  25,  552. 
Mandl.     Beitrag  zur  Frage  des  Verhaltens  der  Uterusmucosa  wahrend  der 

Menstruation.     Arch.  f.  Gyn.,  1896,  52,  557. 

Ueber  das  Epithel  im  Geschlechtsreifen  Uterus.     Zentralb.  f.  Gyn.,  1908, 

32,  425- 
MiNOT.     Human  Embryology.     1892. 

MoRiCKE.  Die  Uterusschleimhaut  in  Verschiedenen  Altersperioden  und  zur 
Zeit  der  Menstruation.     Zeitschr.  f.  Geb.  u.  Gyn.,  1882,  7,  84. 

Ueber  Menstruation  und  Dysmenorrhea.     Halle,  1898. 

Nagel.  Die  Weiblichen  Geschlechtsorgane.  von  Bardeleben's  Handbuch  der 
Anatomie  des  Menschen,  Jena,  1896. 

NoRRis  AND  Keene.  Changes  in  Normal  Endometrium  during  Menstrual  Life, 
based  on  Study  of  100  Cases.     Surg.,  Gyn.  and  Obst.,  1910,  10,  44. 

Sampson.  Influence  of  Myomata  on  Blood  Supply  of  Uterus,  with  Special 
Reference  to  Abnormal  Uterine  Bleeding.  Surg.,  Gyn.  and  Obst.,  1913, 
16,  144. 

Schroder.  Anatomische  Studien  zur  Normalen  und  Pathologischen  Physi- 
ologic des  Menstruationszyklus.     Arch.  f.  Gyn.,  1915,  104,  2.y. 

■ Ueber   die   Zeitlichen   Beziehungen   der   Ovulation   und   Menstruation. 

Arch.  f.  Gyn.,  1914,  loi,  i. 

Die  Driisenepithelveranderungen  der  Uterusschleimhaut  in  Intervall  und 

Pramenstruum.     Arch.  f.  Gyn.,  1909,  88,  i. 

Schickele  und  Keller.     Die  Glandulare  Hyperplasie  der  Uterusschleimhaut. 

Arch.  f.  Gyn.,  1912,  95,  586. 
Schickele.     Die  Lehre  der  Endometritis.     Beitrage  z.  Geb.  u.   Gyn.,   1909, 

13,  358. 

Beitrage  zur  Physiologic  und  Pathologic  der  Ovarien.     Arch.  f.  Gyn., 

1912,  97,  409. 

Schwab.     Zur  Histologic  der  Chronischen  Endometritis.     Zentralb.  f.  Gyn., 

1907,  31,  899. 
de   Sinety.     Recherches  sur  la  muqueuse  uterine  pendant  la  menstruation. 

Gazette  med.,  Paris,  1881,  6  s.,  3,  175. 
Theilhaber.     Die  Ursachen  und  die  Bedeutung  der  Essentiellen  Blutungen 

und  des  Ausflusses.     Arch.  f.  Gyn.,  1914,  102,  165. 
Van  Meerdervoort.     Die    Normale    und    die    Menstruirende    Gebarmutter- 

schleimhaut.     Inaug.  Diss.,  Freiburg  i.  Br.,  1894-95. 


MENSTRUAL  CYCLIC  CHANGES  LN  THE  UTERUS   "       39 

Wendeler.    Demonstration  Mikroskopischer  Priiparate  zweier  Menstruirenden 

Uteri.     Zeitschr.  f.  Geb.  u.  Gyn.,  1895,  32,  316. 
Westphalen.     Zur  Physiologic  der  Menstruation:    Mikroskopische  Studien. 

Arch.  f.  Gyn.,  1896,  52,  37. 
Williams.     The  Normal  Structure  of  the  Uterine  Mucosa  and  its  Periodical 

Changes.     The  Obst.  J.  of  Gt.  Brit,  and  Irel,  1876,  3,  496. 
Young.     The  Structure  of  the  Stroma  of  the  Endometrium,  and  its  Bearing 

on  the  Menstrual  Changes.     Brit.  M.  J.,  1910,  2,  1214. 


CHAPTER  V 

ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  CYCLE, 
INCLUDING  LIFE  CYCLE  OF  CORPUS  LUTEUM 

GROSS  ANATOMY  OF  OVARY 

The  ovaries  are  two  oval  bodies,  situated  one  in  each  side  of  the  pelvis. 
They  are  placed  in  the  posterior  layer  of  the  broad  ligament  much  as  a 
setting  is  placed  in  a  ring.  They  lie  obliquely  in  the  pelvis,  although  their 
position  varies  with  such  factors  as  the  posture  of  the  woman,  the  degree 
of  distention  of  the  bowels  or  bladder,  etc.  At  their  uterine  extremities 
they  are  attached  by  the  ovarian  ligaments  to  the  upper  part  of  the  corpus 
uteri  below  and  behind  the  fallopian  tubes.  At  the  outer  side  the  ovary  is, 
by  means  of  the  fimbria  ovarica,  in  contact  with  the  fimbriated  extremity  of 
the  tube,  beyond  which  the  infundibulopelvic  ligament  stretches  out  to  the 
pelvic  wall.  The  hilum  of  the  ovary,  along  its  attached  surface,  marks  the 
entrance  of  the  ovarian  vessels,  nerves  and  lymphatics. 

The  surface  of  the  ovary  is  of  a  dull  whitish  appearance,  being  covered 
not  by  peritoneum  but  by  the  cuboidal  celled  germinal  epithelium.  In  early 
life  the  surface  of  the  ovary  is  quite  smooth,  but  in  the  adult  woman  it  is 
irregular  and  pitted,  as  a  result  of  the  constant  repetition  of  follicular  rup- 
ture during  the  sexual  life  of  the  woman.  The  senile  ovary  is  shriveled 
and  atrophic,  its  size  being  perhaps  only  half  that  of  the  adult  ovary.  Its 
surface  presents  a  characteristic  "  peachstone  "  appearance. 

Macroscopic  Changes  in  Ovary  as  Result  of  Menstruation. —  Little 
need  be  said  on  this  subject,  for  there  is  no  very  conspicuous  change  in  the 
gross  appearance  of  the  ovary  during  menstruation,  with  the  exception  of 
the  fundamental  phenomena  concerned  with  the  formation  and  development 
of  the  corpus  luteum,  as  will  be  described  in  another  connection.  For  the 
present  we  may  simply  say  that,  according  to  the  modern  view,  the  surface 
of  the  ovary  exhibits  a  recently  ruptured  graafian  follicle  at  some  time 
during  the  first  half  of  the  intermenstrual  period,  for  it  is  at  this  time  that 
ovulation  is  now  believed  to  take  place.  This,  the  earliest  stage  of  corpus 
luteum  formation,  appears  as  a  flattened  vesicle,  with  a  grayish  yellow  wall. 
Its  inconspicuousness  causes  it  to  be  overlooked  in  any  but  the  most  careful 
examination,  as  will  be  discussed  later  in  this  chapter.  At  a  later  period, 
and  especially  during  the  so-called  premenstrual  period,  the  surface  of  the 
ovary  exhibits  a  gradually  developing  corpus  luteum,  reaching  its  maximum 
at  the  onset  of  menstruation. 

Aside  from  this,  the  only  noticeable  changes  which  menstruation  brings 

40 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        41 


about  in  the  ovary  are  those  referable  to  the  increased  blood  supply 
at  that  period.  The  opaque  surface  does  not  indicate  the  hyperemia  of  the 
organs  as  readily  as  might  a  transparent  peritoneal  surface,  but  even  so 
there  is  sometimes  a  somewhat  pinkish  hue  at  and  just  before  the  menstrual 
epochs. 

The  increase  in  the  size  of  the  ovaries  which  is  generally  considered  to 
take  place  at  this  time  is  due  partly  to  the  development  of  the  corpus  luteum 
and  partly  to  hyperemia.  Incision  into  the  ovary  at  this  period  is  associated 
with  more  bleeding  than  at  other  times. 

Histology  of  Ovary. —  Microscopically,  the  ovary  consists  of  a 
fibrous  stroma,  in  which  are  found  the  epithelial  elements  which  constitute 


Fig.  8. —  Developing  Follicle  (Williams). 

the  functionating  part  of  the  organ.  While  some  authors  have  suggested 
that  the  stromal  tissue  of  the  ovary  is  also  concerned  in  the  production  of 
an  internal  secretion,  the  evidence  for  this  view  is  inconclusive.  From  our 
present  viewpoint,  therefore,  we  may  dismiss  the  stroma  of  the  ovary  by 
merely  stating  that  it  is  made  up  of  a  more  or  less  spindle  celled,  compact 
fibrous  tissue  (Fig.  8)  ;  that  it  supports  the  epithelial  elements;  and  that 
it  carries  the  blood  vessels,  lymphatics,  and  nerves  of  the  ovary. 

The  important  constituents  of  the  ovary,  from  a  functional  viewpoint, 
are  (i)  th.Q  follicles;  {2)  the  corpora  lutea;  {2)  the  interstitial  cells.  Em- 
bryologically,  all  three  of  these  elements  are  believed  to  have  a  common 
origin  in  the  early  germ  cells  or  oogonia  (Waldeyer,  von  Winiwarter, 
Skrobansky,  McElroy), 


42 


MENSTRUATION  AND  ITS  DISORDERS 


THE  FOLLICLES  OF  THE  OVARY 

The  Primordial  Follicle. —  The  early  stage  of  follicular  development 
—  the  priiiwrdial  follicle  —  possesses  a  very  simple  structure.  It  consists 
of  the  primordial  ovum,  or  oocyte,  surrounded  by  a  single  layer  of  flattened 
epithehal  cehs.  At  a  slightly  later  period,  the  latter  become  cuboidal  in 
shape,  while  the  fohicle  increases  in  size  as  a  result  of  the  appearance  of  the 
so-called  liquor  folliculi.      (Figs.  8  and  9.) 

The  Graafian  Follicle. —  The  epithelial  envelope,  or  membrana 
granulosa,  proliferates  rapidly,  so  that  it  becomes  several  layers  thick.     At 


^{•ji 


'Jit 


.*t*^i 


^!#-; 


V,, 


■m 


3'^ 

^^L 
"•'-,% 


MrM 


Fig.  9. —  Developing  Follicle  ;  Later  Stage  Than  Fig.  8 
(Williams). 

one  point  in  the  circumference  of  the  follicle,  the  granulosa  cells  are  heaped 
up  in  a  peninsula-like  mass  which  surrounds  the  ovum.  This  projection  is 
spoken  of  as  the  discus  proligcrus.  At  the  same  time  the  connective 
tissue  sheath  of  the  follicle,  the  thcca  folliculi,  shows  a  differentiation  into 
two  layers.  The  outer,  or  thcca  externa,  does  not  differ  in  structure  from 
the  adjoining  ovarian  stroma.  The  inner,  or  thcca  interna,  exhibits  a  slight 
differentiation  of  its  cells,  which  become  somewhat  oval  or  polygonal  and 
rather  compactly  placed.     The  inner  layer  also  becomes  more  vascular. 

In  the  fully  developed  graafian  follicle,  the  ovum  is  surrounded  by  a 
layer  of  radially  placed  cells  of  the  granulosa,  the  corona  radiata.     Between 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        43 

the  latter  and  the  ovum  is  a  narrow  transparent  zone,  the  coiia  pcUucida. 
The  so-cahed  pcriz'itclliiic  space  Hes  btweeen  the  zona  pehucida  and  the 
ovum.  The  envelope  of  the  ovum  itself  is  the  vitelline  uieiiibraiie,  while  its 
nucleus  is  the  germinal  vesicle,  and  its  nucleolus  the  germinal  spot.  The 
protoplasm  of  the  ovum,  finally,  consists  of  the  dentoplasm,  or  yolk,  and 
the  protoplasm  proper.      (Fig.  lo. ) 

THE  CORPUS  LUTEUM 

General. —  There  is  no  one  subject  in  gynecology  which  has  received 
so  much  study  in  recent  years  as  that  of  the  histogenesis  and  function  of. 


L-r-t:o>/^^!v,^"^5£/f<.4/M 


Fig.  10. —  Follicle  Approaching  Maturity. 

D,  discus  proligerus;   M.G.,  membrana  granulosa;   T.  ex.,  tunica  externa;   T.  int.,  tunica 
interna  (Williams). 


the  corpus  luteum.  To  the  development  of  our  knowledge  of  this  subject, 
is  largely  due,  as  a  corollary,  our  increased  knowledge  of  the  physiology  of. 
menstruation.  The  remarkable  series  of  studies,  beginning  with  that  of 
Fraenkel  in  1903,  and  including  the  work  of  Robert  Meyer,  Ruge,  Schroder, 
Miller,  and  others,  have  revolutionized  our  ideas  of  the  physiology  of  men- 
struation, and  of  the  relation  of  this  process  to  ovulation. 

Older  Views  as  to  Corpus  Luteum. —  Previous  to  the  contribution-of 
Fraenkel  in  1903,  the  corpus  luteum  was  commonly  described  as  the  end^ 
product  of  the  graafian  follicle.     After  the  rupture  of  the  latter  at  ovula-. 
tion,  there  was  said  to  be  a  hemorrhage  into  the  cavity  of  the  follicle, 
together  with,  or  —  according  to  some  —  preceded  by,  the  appearance  of  the 


44  MENSTRUATION  AND  ITS  DISORDERS 

so-called  lutein  layer.  For  many  years  there  had  been  a  controversy  as  to 
the  origin  of  the  lutein  cells,  some  maintaining  that  they  arise  from  the 
connective  tissue  cells  of  the  theca  interna,  others  that  they  are  formed  from 
the  epithelial  cells  of  the  membrana  granulosa.  As  we  shall  see,  opinion  is 
even  now  not  unanimous  on  this  point. 

The  later  history  of  the  corpus  luteum  was  described  by  the  older  authors 
as  depending  upon  whether  or  not  pregnancy  supervenes  upon  ovulation. 
If  it  does,  the  resulting  corpus  luteum  —  the  true  corpus  luteum  or  corpus 
luteum  verum  —  not  only  does  not  immediately  retrogress,  but  actually  and 
markedly  increases  in  size  up  to  the  third  or  fourth  month  of  pregnancy, 
after  which  retrograde  changes  appear.  On  the  other  hand,  if  pregnancy 
fails  to  occur,  the  resulting  corpus  luteum  spurium,  or  false  corpus  luteum, 
begins  to  diminish  in  size  almost  at  once.  The  blood  clot  becomes  gradually 
organized,  the  lutein  layer  more  and  more  convoluted,  the  cells  gradually 
losing  their  pigment,  until  finally  only  a  convoluted  cicatricial  body,  the 
corpus  Hhrosum  or  corpus  albicans,  marks  the  site  of  the  former  graafian 
follicle.  In  the  case  of  the  corpus  luteum  of  pregnancy,  similar  retrogres- 
sive changes  occur,  except  for  the  long  delay  in  their  appearance.  In  either 
event,  no  physiological  function  was  ascribed  to  the  corpus  luteum  by  the 
older  authors. 

Modern  Conception  of  Corpus  Luteum. —  Although  it  v^as 
Fraenkel's  work  which  gave  the  impetus  to  the  study  of  the  corpus  luteum,  his 
investigations  were  concerned  with  the  physiological  function  of  the  corpus 
luteum  rather  than  with  its  origin  and  structure.  It  is  with  the  latter  sub- 
jects that  we  are  especially  concerned  in  the  present  chapter.  The  epoch- 
making  demonstration  by  Hitschmann  and  Adler  that  the  endometrium 
undergoes  a  cyclical  variation  corresponding  to  the  various  phases  of  the 
menstrual  cycle  suggested  the  inquiry  as  to  whether  the  corpus  luteum  of 
menstruation  also  passes  through  a  series  of  stages  corresponding  to  the 
various  stages  of  the  menstrual  cycle.  That  this  is  actually  the  case  was 
demonstrated  by  Robert  Meyer  in  191 1,  and  has  since  then  been  confirmed 
by  a  number  of  other  investigators. 

In  view  of  the  frequent  fallibility  of  the  menstrual  anamnesis,  it  seemed 
more  scientific  to  fix  the  exact  period  in  the  menstrual  period  by  the  histo- 
logical appearance  of  the  endometrium  rather  than  by  the  patient's  state- 
ments. Since  there  is  no  longer  any  doubt  of  the  sequence  of  histological 
changes  in  the  endometrium,  such  a  criterion  would  seem  to  be  free  from 
objection.  Schroder  believes  that  the  exact  period  of  the  cycle  at  which 
an  endometrium  has  been  removed  can,  by  microscopic  examination,  be 
determined  within  a  margin  of  two  days.  It  is  probable  that  there  are  few 
who  would  make  pretense  to  such  diagnostic  precision  as  this.  There  is  no 
difficulty,  however,  in  determining  the  stage  at  which  the  endometrium  is 
removed  —  whether  postmenstrual,  interval,  premenstrual,  or  menstrual  — 
and  this,  after  all,  is  the  important  point.      (Chapter  IV.) 

Using  the  histological  changes  in  the  endometrium  as  a  criterion,  Meyer 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD       45 


was  able  to  describe  the  development  of  the  corpus  luteum  by  corresponding 
stages,  from  its  formation  after  ovulation  to  its  ultimate  fate.  It  is  now- 
possible  to  determine  the  stage  of  development  of  a  corpus  luteum  from  its 
histological  appearance. 

The  failure  of  earlier  observers  to  describe  the  life  history  of  the  corpus 
luteum  was  in  a  large  measure  due  to  the  error  of  studying  only  what 
macroscopically  were  looked  upon  as  recent  corpora  lutea,  i.  e.,  those  struc- 
tures which  possess  the  characteristic  yellow  wall  and  which  usually  contain 
blood  in  their  lumina.  In  this  way  the  small  thin  walled  structures,  often 
without  bloody  contents,  which  represent  the  very  early  stages  of  the  cor- 
pora lutea,  received  scant  attention. 


M.G. 


Fig,  11. —  Section  Through  Wall  of  Mature  Follicle  (highly  magnified). 

("Williams). 
M.G.,  membrana  granulosa;  T.I.,  tunica  interna;  T.E.,  tunica  externa. 

Life   Cycle  of  Corpus  Luteum. —  The  life   history  of   the  corpus 

luteum  may  be  divided  into  four  stages:  (i)  the  stage  of  proliferation; 
(2)  the  stage  of  vascularization;  (3)  the  stage  of  maturity;  (4)  the  stage 
of  retrogression. 

The  Stage  of  Proliferation. —  Preceding  the  rupture  of  the  follicle 
certain  rather  characteristic  changes  are  noted  in  its  wall  —  changes  which 
are  indicative  of  maturation  of  the  follicle.  The  cells  of  the  theca  interna' 
become  larger  and  clearer,  gradually  losing  their  connective  tissue  char-acter, 
so  that  all  grades  of  transition  may  be  noted  between  the  spindle  cells  of 
the  theca  externa  and  the  polygonal  cells  of  the  theca  interna.  The  division 
between  these  two  layers  is  therefore  not  very  distinct.  The  theca  interna, 
on  the  other  hand,  separates  itself  from  the  membrana  granulosa,  which 
becomes  much  increased  in  thickness. 


46 


MENSTRUATION  AND  ITS  DISORDERS 


The  cells  of  the  granulosa  may  show  mitoses  and  other  evidences  of  pro- 
liferation, usually  hecoming"  cubocylindrical  in  shape.  These  changes,  it 
may  be  added,  are  not  uniform  in  all  parts  of  the  follicle  wall.  All  this,  it 
must  be  borne  in  mind,  occurs  before  the  follicle  wall  has  ruptured,  and 
may  be  looked  upon  as  a  preliminary  to  the  more  active  proliferative 
changes  characteristic  of  the  early  stages  of  the  corpus  luteum  itself. 
(Fig.  II.) 

The  process  of  rupture  of  the  follicle,  as  already  stated,  does  not  always 


Fig.  12. —  Portion  of  Wall  of  Early  Corpus  Luteum,  Eemoved  on  Tenth  Day  of  Cycle 

(low  power). 

mg,  membrana   granulosa;    th,  theca  interna.     Note  the  vascular  line   of  demarcation 
between  these  two  layers. 


involve  bleeding  into  the  cavity  of  the  lumen,  and,  as  a  matter  of  fact,  bleed- 
ing is  by  some  (Ruge)  looked  upon  as  exceptional.  With  the  evacuation 
of  the  liquor  folliculi  it  often  happens  that  not  only  does  the  ovum  with 
the  "  cumulus  ovigerus  "  escape,  but  that  here  and  there  the  inner  layers  of 
the  granulosa  are  denuded  and  that  perhaps  even  the  theca  interna  is 
entirely  separated  in  places  from  the  granulosa.  The  capillaries  of  the  theca 
externa  and  interna  are  widely  dilated,  blood  elements  not  infrequently 
being  found  in  the  tissue  surrounding  the  follicle. 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD       41 


The  theca  cells,  which  in  the  ripening  follicle  form  a  compact  layer 
around  the  granulosa,  are  in  the  stage  of  proliferation  more  or  less  separated 
by  the  vascular  dilatation,  bleeding  and  edema,  presenting  a  rather  disorderly 
appearance  as  a  result.  I  have  elsewhere  emphasized  the  subgranulosal 
vascular  zvreath  which  sharply  marks  off  the  theca  from  the  granulosa. 
(Figs.  12  and  13.) 

The  size  of  the  theca  cells  increases,  especially  because  of  fatty  infiltration, 
which  correspondingly  diminishes  their  staining  capacity.  Meyer  lays 
stress  upon  the  enormous  increase  in  the  fatty  content  of  both  the  granulosa 
cells  and  those  of  the  theca.  Miller  denies  that  neutral  fat  is  to  be  found  in 
the  cell  layers  of  the  young  corpus  luteum,  while  lipoid  substances,  on  the 


Fig.  13. —  High  Powee  Picture  of  Corpus  Luteum  Shown  in  Fig.  12. 
Compare  with  Fig.  14. 

other  hand,  are  present.  Only  in  the  stage  of  retrogression,  l^e  states,  is 
neutral  fat  found  in  the  corpus  luteum.  He  further  asserts  that  the  yellow 
color  assumed  by  the  lutein  cells  is  due,  not  to  the  presence  of  neutral  fat, 
but  to  the  formation  or  deposit  of  a  special  pigment. 

The  granulosa  cells  become  more  and  more  polygonal,  take  the  stain  less 
deeply,  and  gradually  become  converted  into  the  so-called  lutein  cells.  (Fig. 
14.)  This  latter  change  takes  place  quite  unevenly,  so  that  at  different 
points  in  the  same  corpus  luteum  may  be  seen  clearly  differentiated  lutein 
cells  and  more  or  less  unchanged  granulosa  cells. 

Grossly,  the  very  early  corpus  luteum  appears  as  a  thin  walled,  collapsed 


48  MENSTRUATION  AND  ITS  DISORDERS 

vesicie  on  the  surface  of  the  ovary.  The  point  of  rupture  may  be  evident, 
but  hemorrhage  into  the  himen  is  not  characteristic.  The  wahs,  however, 
are  usuahy  hyperemic,  possibly  giving-  tlie  vesicle  a  hemorrhagic  appear- 
ance. The  inner  surface  is  of  a  yellowish  gray  hue,  and  the  wall  presents 
only  a  slight  degree  of  undulation. 

The  Stage  of  Vascularization. —  This,  the  second  stage  in  the  devel- 
opment of  the  corpus  luteum,  begins  with  hemorrhage  from  the  greatly 
dilated  theca  capillaries  into  the  granulosa  layer  and  into  the  lumicn.  At 
the  same  time  endothelial  cells  from  the  vessels  of  the  theca  interna  push 


*.^^**%C 


Fig.  14. —  Wall  of  Early  Corpus  Luteum,  Slightly  More  Advanced  Than  That  Shown 

IN  Fig.  20  (Mgli  power). 

Note  the  lutein-like  change  of  granulosa  cells,  and  beginning  retrogression  of  theca  cells. 

between  the  granulosa  cells  up  to  the  lumen  of  the  corpus  and  form  new 
capillaries  in  the  epithelial  zone.  This  process  of  vascularization  proceeds 
quite  rapidly,  and  hence  is  overlooked  by  a  good  many  investigators.  Only 
rarely,  as  in  the  case  pictured  by  Meyer,  does  the  beginning  of  the  process 
of  vascularization  come  under  observation ;  usually  the  entire  granulosa  has 
been  permeated  with  blood  when  the  corpus  luteum  is  obtained  for  study. 
In  the  outer  layer  of  the  epithelial  zone  the  blood  is  contained  in  the  vessels, 
while  toward  the  cavity  it  may  lie  free  between  the  epithelial  cells.  (Fig.  15.) 
While  vascularization  is  the  most  important  and  the  most  conspicuous 
feature  of  this  stage,  changes  in  the  epithelium  are  also  noted.     The  cells 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD 


49 


become  more  distinctly  lutein-like,  the  epithelial  zone  being  cjuite  clearly- 
marked  off  from  the  theca  interna. 

The  endothelial  cells  during  the  process  of  vascularization  often  push 
beyond  the  inner  border  of  the  lutein  cells  into  the  extravasated  blood  in  the 
lumen.  Connective  tissue  cells  also  not  infrequently  penetrate  the  epithelium 
and  invade  the  lumen.    The  inner  margin  of  the  lutein  layer  is  thereby  given 


'*Sr*-''% 


t  4 


A  ^l 


';/*« 


■■■  M 

*   *  Ik  ■ 

,4' 

Fig.  15. —  Wall  of  Corpus  Ltjteum  in  Stage  of  Eakly  Vascularization,  Sixteenth 

Day  (high  power). 

Blood  vessels  from  the  theca  are  pushing  into  the  granulosa  layer  (1) ,  which  now  possesses 
definite  lutein  characteristics.  The  theca  cells  (th)  have  lost  their  fat  and  are  retrogress- 
ing.    Is'ote  the  beginning  invasion  of  the  blood  in  the  cavity   (c)  by  endothelial  cells. 

a  very  irregular  appearance.  Gradually  there  is  developed  on  this  inner 
border  a  layer  of  connective  tissue  cells  and  blood  vessels  which  forms  a 
sharp  dividing  line  between  the  lutein  cells  and  the  blood  within  the  lumen. 
In  this  stage  the  wall  of  the  corpus  luteurri  becomes  bright  yellow  in  color 
and  takes  on  a  moderately  wavy  outline.     Blood  now  becomes  apparent  in 


50 


MENSTRUATION  AND  ITS  DISORDERS 


the  lumen,  usually  as  a  narrow  zone  along  the  inner  margin  of  the  lutein 
layer,  although  sometimes  the  lumen  is  practically  tilled. 

The  Stage  of  jMaturity. —  The  completion  of  vascularization  and  the 
formation  of  the  dividing  membrane  between  the  lutein  layer  and  the  con- 
tents of  the  lumen  indicate  that  the  corpus  luteum  has  reached  the  point  of 
maturity.  (Fig.  i6.)  From  now  on  it  functionates  as  a  ductless  gland, 
giving  off  its  secretion  into  the  blood  stream,  instead  of  i-nto  the  lumen. 
The  lutein  cells  become  larger  and  more  or  less  polygonal.  The  lutein  zone 
as  a  whole  assumes  a  more  and  more  undulating  outline,  owing  to  the  rapid 


Fig.  16. —  Wall  of  Mature  Corpus  Luteum,  Twenty-seventh  Day  (low  power),  showing 
lutein  (1)  and  paralutein  (p)  cells.     The  latter  are  found  in  the  Avedge-like  septa. 


relative  increase  in  the  cells  as  compared  to  the  surrounding  tissue.  Not 
infrequently  the  large  size  and  alveolar  arrangement  of  the  theca  cells  — 
the  so-called  "  paralutein  "  cells  —  suggests  an  internal  secretory  function. 
(Fig.  17.) 

In  this  stage  the  corpus  luteum  appears  as  a  conspicuous  yellow-walled 
structure,  varying  usually  from  i  to  2  cm.  in  diameter.  The  lutein  layer  is 
very  undulating,  and  the  position  of  the  corpus  luteum  is  usually  marked  on 
the  surface  of  the  ovary  by  a  dark  reddish,  hemorrhagic  mound.     (Fig.  18.) 

The   Stage   of   Retrogression. —  This   stage   is  characterized   by  a 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        51 

shrivelling  of  the  lutein  layer  as  a  result  of  the  development  of  connective 
tissue  fibrils  between  the  cells.  The  process  of  organization  in  the  contents 
of  the  lumen  advances  progressively,  while  the  theca,  already  less  distinct, 
disappears  entirely  in  this  stage.  These  retrogressive  changes  do  not  pro- 
ceed with  the  same  degree  of  rapidity  in  all  cases.  The  theca  cells  may 
still  be  large  and  numerous  in  the  stage  of  retrogression  of  the  corpus 


Fig.   17.- 


CoNTRAST   Between   Lutein   and   Paralutein   Cells,   Near   Top   of   Septum 
Shown  at  p  in  Fig.  16  (high  power). 


luteum,  while  in  other  cases  they  are  quite  sparse  even  in  the  stage  of 
maturity.  In  the  same  way  organization  of  the  blood  in  the  lumen  may  be 
quite  advanced  in  the  beginning  of  the  stage  of  maturity,  although  it  does 
not  become  marked  until  the  lutein  cells  show  much  retrogression. 

There  is  no  sharp  dividing  line  between  the  stage  of  maturity  and  that  of 
retrogression.     One  blends  gradually  into  the  other.     I  have  often  found  it 


^2  MENSTRUATION  AND  ITS  DISORDERS 

impossible  to  distinguish  corpora  Intea  removed  just  after  menstruation  from 
those  removed  just  before,  even  though  retrogressive  changes  are  said  to 
set  in  with  the  onset  of  menstruation.  The  individual  variation  in  the 
rapidity  of  retrogression  is  illustrated  by  the  fact  that  in  some  cases  four 
or  five  v\^ell  marked  corpora  lutea,  in  various  stages  of  retrogression,  may  be 
observed,  vy^hile  in  others  only  one  is  noted. 

There  has  been  much  discussion  as  to  the  significance  of  fatty  changes  in 
the  lutein  cells.  This  is  a  prominent,  though  probably  not  a  characteristic 
feature  of  this  stage.  Together  with  this,  it  will  be, seen  that  the  connective 
tissue  trabeculae  ramify  more  boldly  through  the  lutein  zone,  while  organ- 
ization of  the  contents  becomes  more  advanced,  the  process  being  due  to 


■ 

i                                                                                                     i 

1  ■ 
h 

'. 
t 

"^^^^ 

l^^r--- 

Fig.  18. —  A  Transverse  Section  of  the  Ovart,  About  Three  Times  the  Normal  Size, 
Showing  a  Labge,  Mature  Corpus  Luteum. 

It  embraces  about  half  the  cross  section  of  the  ovary.     Note  the  festooned  lutein  layer, 
and  the  narrow  zone  of  blood  just  within  it. 

invasion  by  the  endothelial  and  connective  tissue  cells  of  the  lutein  layer. 
The  central  core  of  organizing  tissue  on  the  inner  side  and  the  theca  at 
the  outside  are  thus  connected  by  a  gradually  shrinking  fibrous  meshwork, 
showing  more  and  more  evidence  of  hyaline  change.  Little  by  little  the 
lutein  cells  are  crushed  out,  until  finally,  in  the  corpus  albicans,  there 
remains  only  tlie  shrunken  and  hyalinized  outline  of  the  wavy  lutein  layer, 
surrounding  the  central  core  of  well  formed  connective  tissue.  The  sharp- 
ness of  outline  of  the  hyalinized  lutein  layer,  both  internally  and  externally, 
is  worthy  of  note,  indicating  the  remarkable  special  reaction  of  the  lutein 
cell,  even  after  its  death.      (Figs.  19  and  20.) 

Chronological  Relation  of  Corpus  Luteum  Cycle  to  Menstrual  and 
Endometrial  Cycles. —  The  study  of  a  large  number  of  corpora  lutea 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        53 

with  reference  to  the  histological  appearance  of  the  endometrium  at  differ- 
ent stages  of  the  menstrual  cycle  shows  that  a  very  definite  relation  exists 
between  the  two.  This  relation  is  confirmed  by  a  study  of  the  menstrual 
histories  in  such  cases.  Meyer  and  Ruge  state  that  the  stage  of  prolifera- 
tion begins  at  any  time  between  the  first  and  the  fourteenth  days  of  the 
menstrual  cycle,  the  first  day  of  menstruation  being  considered,  of  course, 
as  the  beginning  of  the  cycle  of  twenty-eight  days.  This  is  another  way  of 
saying  that  ovulation  occurs  at  some  time  between  the  first  and  fourteenth 
days  of  the  cycle. 


Fig.  19. —  Corpus  Luteum  Showing  BEonrNiNG  of  Eetrogeession  (low  power). 


Miller,  on  the  other  hand,  places  the  time  of  follicular  rupture  at  about 
the  eighteenth  day  of  the  cycle,  i.  e.,  about  nine  days  before  menstruation. 
Schroder,  again,  on  the  basis  of  a  large  number  of  observations,  states  that 
ovulation  occurs  between  the  fourteenth  and  sixteenth  days  of  the  cycle. 
My  own  investigations,  which  include  the  study  of  a  large  amount  of  mate- 
rial, would  indicate  that  while  the  time  of  ovulation  differs  in  different 
women,  it  can  usually  be  placed  between  the  fifth  and  fourteenth  days  of 
the  cycle. 

The  stage  of  vascularization  in  the  corpus  luteum  corresponds  to  the 
latter  portion  of  the  interval  stage  in  the  endometrial  cycle,  while  the  full 
development  of  the  corpus  luteum,  i.  e.,  the  stage  of  maturity,  is  associated 
with  the  hypertrophic  and  secretory  changes  so  characteristic  of  the  pre- 


54 


MENSTRUATION  AND  ITS  DISORDERS 


menstrual  period  in  the  uterine  mucosa.  Finally,  the  onset  of  menstruation 
initiates  the  retrogressive  stage  in  the  cycle  of  the  corpus  luteum.  This 
subject,  however,  is  discussed  more  fully  in  Chapter  XVI. 

The  time  relation  existing  between  menstruation,  the  histological  appear- 


FiG.  20. —  A  Corpus  Albicans. 
Note  the  sharp  outline  of  the  hyalinized,  festooned,  lutein  zone. 

ance  of  the  endometrium,  and  the  stage  of  development  of  the  corpus  luteum 
is  concisely  summed  up  by  Schroder  somewhat  as  follows : 

Fii'st  Stage.  15th  to  20th  day  of  menstrual  cycle. —  Endometrium  shows 
midinterval  or  late  interval  picture.  Corpus  luteum  is  in  its  earliest  stage 
of  development.  Granulosa  cells  still  small,  but  gradually  becoming  larger. 
Increasing  folding  of  epithelial  layer  is  noted,  with  numerous  red  blood 
corpuscles  between  the  cells.  The  inner  boundary  of  the  granulosa  zone  is 
indistinct.  The  formation  of  new  capillaries  is  beginning.  The  cells  of 
the  theca  interna  are  large,  but  gradually  become  smaller. 


ANATOMIC  CHANGES  Tst  OVARY  DURING  MENSTRUAL  PERIOD        55 

Second  Stage.  i8th  to  25th  day  of  menstrual  cycle. —  Endometrium 
shows  premenstrual  picture  in  its  earlier  stages.  Corpus  luteum  ripe  (stage 
of  vascularization).  Granulosa  cells  broad  and  large,  the  epithelial  zone 
being  markedly  convoluted.  Fine  fibrils  with  capillaries  traverse  it,  usually 
in  a  radial  manner.  Delicate  but  quite  distinct  connective  tissue  layer  on 
inner  margin  of  epithelial  layer.     Theca  interna  cells  small. 

Third  Stage.  24th  to  28th  day  of  menstrual  cycle. —  Endometrium 
shows  changes  of  end  of  premenstrual  period.  Corpus  luteum  completely 
formed  and  entirely  organized.  Granulosa  as  in  second  stage.  Fibrils  and 
capillaries  more  numerous,  with  numerous  anastomoses  of  latter.  Well 
defined  limiting  membrane  of  connective  tissue  at  inner  margin  of  lutein 
cells. 

Fourth  Stage,  ist  to  14th  day  of  menstrual  cycle. —  Endometrium  shows 
postmenstrual  and  early  interval  change.  Corpus  luteum  in  retrogression. 
Granulosa  cells  shriveling  up,  interspersed  with  increasing  fibrillary  con- 
nective tissue  growth.  Connective  tissue  membrane  at  inner  margin  of 
granulosa  thickened,  and  advancing  organization  of  lumen  contents.  Theca 
interna  quite  distinct  peripherally,  its  cells  being  clear  and  well  formed. 

Comparison  of  Corpus  Luteum  of  Menstruation  and  Corpus  Luteum 
of  Pregnancy. —  Practically  the  only  difference  described  by  the  older 
authors  between  these  two  structures,  the  corpus  luteum  spurium  (men- 
struationis) ,  or  false  corpus  luteum,  and  the  corpus  luteum  verum  {gravidi- 
tatis),  or  true  corpus  luteum,  lay  in  the  longer  life  of  the  latter.  Even  this 
was  ascribed  to  extrinsic  conditions,  especially  the  pelvic  hyperemia 
associated  with  pregnancy. 

Many  of  the  more  recent  authors,  such  as  Ravano,  Hegar  and  Wolz, 
describe  no  essential  difference  between  the  two  structures,  other  than  the 
difference  in  the  periods  during  which  they  persist.  Such  an  opinion  was 
not  surprising  in  the  days  when  the  corpus  luteum  was  looked  upon  only 
as  an  end  product  of  the  graafian  follicle,  but  it  scarcely  seems  tenable  in 
the  light  of  the  present  day  belief  in  the  role  of  the  corpus  luteum  as  a 
ductless  gland  wdiich  is  important  both  for  menstruation  and  for  pregnancy. 

It  was  Aschoff  who  first  asserted  that  a  point  of  differentiation  between 
the  two  was  the  usual  absence  of  bleeding  in  the  corpus  luteum  of  preg- 
nancy. He  believed  that  ovulation  takes  place  in  the  intermenstrual  periods, 
and  that  the  hemorrhage  in  the  lumen  of  the  corpus  luteum  of  menstruation 
is  due  to  the  hyperemia  of  the  menstrual  process. 

Mention  has  already  been  made  of  the  work  of  Miller,  who  found  colloid " 
material  in  the  lutein  cells  of  the  true  corpus  luteum,  and  emphasized  the 
importance  of  this  finding  for  purposes  of  differentiation. 

The  most  complete  study  of  this  question,  however,  is  the  recent  one  by 
Marcotty,  based  on  a  material  consisting  of  26  corpora  lutea  of  pregnancy, 
2  corpora  lutea  removed  during  the  puerperium,  and  14  corpora  lutea  of 
menstruation. 


56 


MENSTRUATION  AND  ITS  DISORDERS 


Marcotty  found,  first  of  all,  that  the  curve  of  blood  pigment  present  in 
the  corpus  luteum  alternates  with  the  menstruation  curve,  having  its  begin- 
ning in  the  middle  of  the  intermenstrual  period.  He  agrees  with  Meyer 
that  hemorrhage  in  the  corpus  luteum  is  normally  present,  even  before  the 
onset  of  the  menstrual  period,  and  that  it  is  therefore  due  to  a  rupture  of 
the  thin  walled  vessels  found  in  the  stage  of  vascularization,  under  the 
influence  of  the  increased  blood  pressure  in  the  pelvic  circulation.  The 
influence  of  the  menstrual  congestion  itself  is  manifested  by  a  renewed 
bleeding  at  the  time  of  the  period. 


Fig.  21. —  Corpus  Luteum  in  a  Case  of  Early  Pregnancy  (low  power),  showing  lutein 
cells  (1),  paralutein  cells  (p),  and  organization  of  contents  (e). 

In  the  corpus  luteum  of  pregnancy,  on  the  other  hand,  the  hemorrhage 
due  directly  to  the  menstrual  influence  is  of  course  absent,  while  that  asso- 
ciated with  the  process  of  vascularization  is  not  constant,  apparently  owing 
to  different  conditions  of  blood  pressure  and  blood  distribution. 

The  size  of  the  true  corpus  luteum  before  its  retrogression  begins  exceeds 
the  greatest  size  of  the  false  corpus.  Up  to  perhaps  the  second  month  this 
larger  size  is  due  to  the  hypertrophy  of  the  granulosa  layer  and  the  develop- 
ment of  the  lutein  zone,  after  that  to  the  development  of  the  central  core. 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        57 

In  the  corpus  hiteum  of  pregnancy,  moreover,  the  connective  tissue  mem- 
brane between  the  himen  contents  and  the  kitein  layer  is  much  more  marked 
than  in  the  corpus  kiteum  of  menstruation.  (Fig.  21.)  The  differences 
between  the  two  structures  are  epitomized  by  jNIarcotty  in  tabular  form,  as 
follows : 

Corpus  Luteum  jMenstruationis 


Before  menstruation. 

After  menstruation. 

Blood. 

nfrequent,  small  amount. 

regularly,  abundant. 

Blood  pigment. 

little. 

much. 

Fat. 

little,  chiefly  in  theca. 

much,       principally 
granulosa. 

Colloid. 

absent. 

absent. 

Calcium. 

absent. 

absent. 

Size  of  organ. 

increasing  to  menstruation 

,  then  decreasing. 

Size  of  cavity. 

usually  small. 

organized. 

Connective  tissue 

cover- 

ing. 

slight. 

well  defined. 

Size  of  granulosa 

cells. 

average. 

atrophic. 

Theca  cells. 

conspicuously  present. 

in  diminishing  numt 

Connective  tissue 

frayne- 

zvork   and   bloc 

^d   ves- 

sels. 

slight. 

marked. 

in 


Corpus  Luteum  Graviditatis 

1st  half  2nd  half 


Blood. 

usually  not  present. 

Pigment. 

except  perhaps  traces. 

Fat. 

very  little 

more  toward  end 

Colloid. 

frequent,  abundant 

less  frequent,  less  abun- 
dant. 

Calcium. 

absent 

rather  frequent. 

Size  of  0 

rgan. 

larger    than    corpus    lu- 
teum of  menstruation. 

smaller  than  in  first  half, 

Size  of  cavity. 

large,  cystic. 

smaller,  more  frequently 

Connective  tissue. 
Size  of  granulosa  cells. 
Theca  cells. 


Connective  tissue  frame- 
work and  blood  ves- 
sels. 


very  well  marked. 

larger  than  average. 

almost  always  present, 
but  owing  to  flatten- 
ing not  conspicuous. 

fairly  well  marked. 


solid, 
well  marked, 
smaller  than  average, 
gradually  disappearing. 


well  marked. 


58  MENSTRUATION  AND  ITS  DISORDERS 

ORIGIN  OF  LUTEIN  CELLS 

No  subject  concerned  with  the  corpus  kiteum  has  been  the  source  of  more 
study  and  discussion  than  the  origin  and  nature  of  the  lutein  cehs.  An 
extensive  Hterature  has  developed  on  this  subject.  Only  a  brief  summary 
of  this  interesting  question  can  be  included  here. 

Two  Principal  Theories. —  There  are  tw^o  principal  views  as  to  the 
origin  of  the  lutein  cells.  According  to  one  of  these  the  lutein  cells  are 
derived  from  the  connective  tissue  cells  of  the  theca  interna,  and  according 
to  the  other  they  have  their  origin  in  the  epithelial  cells  of  the  membrana 
granulosa.  The  first  of  these  was  supported  by  von  Bar,  the  discoverer 
of  the  human  ovum,  and  since  then  by  His,  von  Kolliker,  Spiegelberg, 
Paladino,  Schottlander,  Clark,  Nagel  and  many  others.  On  the  other  hand, 
the  theory  of  the  epithelial  genesis  of  the  lutein  cells  has  found  able  sup- 
porters in  Bischoff,  Pfluger,  Call  and  Exner,  Schulin,  Waldeyer,  Sobotta 
and  others.  The  latter  theory,  moreover,  is  favored  by  most  of  the  modern 
German  school  of  investigators  who  have  contributed  so  much  tO'  our 
knowledge  of  the  corpus  luteum  (Meyer,  Ruge,  Schroder,  etc.). 

Origin  of  Lutein  Cells  in  Lower  Animals. —  The  question  of  the 
origin  of  the  lutein  cells  in  the  lower  animals  has  been  quite  conclusively 
settled  by  the  exhaustive  researches  of  Sobotta  on  rabbits,  guinea  pigs,  mice, 
and  other  mammals.  Sobotta's  studies  indicate  that  in  the  lower  animals, 
at  least,  it  is  from  the  epithelial  cells  of  the  membrana  granulosa  that  the 
lutein  cells  are  derived. 

Theory  of  Origin  from  Connective  Tissue. —  The  view  that  the  lutein 
cells  have  a  connective  tissue  origin,  as  Williams  says,  is  based  upon  two 
principal  facts :  first,  that  the  cells  of  the  theca  interna  exhibit  marked 
changes  immediately  after  the  rupture  of  the  follicle;  and  second,  that 
degenerative  changes  are  noted  in  the  cells  of  the  granulosa,  which,  as  a 
matter  of  fact,  is  in  large  part  cast  off  with  the  ovum.  The  changes  in  the 
theca  consist  in  the  appearance  of  mitoses  and  other  evidences  of  prolifera- 
tion, the  cells  becoming  larger  and  assuming  an  epithelioid  appearance. 
This  is  noted  even  in  the  earlier  stages  of  follicular  development.  The 
yellow  color  of  the  lutein  cell  is  due  to  the  deposit  of  a  special  pigment. 
The  fact  that  "  the  lutein  cells  first  appear  in  the  theca  would  argue  against 
their  derivation  from  the  membrana  granulosa,  but  even  more  so  the  fact 
that  they  are  separated  from  it  by  a  definite  barrier  of  unchanged  connective 
tissue,  the  upper  layer  of  which  forms  the  basement  membrane  of  the 
follicle"  (Williams). 

Theory  of  Epithelial  Origin  of  Lutein  Cells. —  As  for  the  evidence  in 
favor  of  the  epithelial  origin  of  the  lutein  cells  mention  may  first  be  made 
of  the  work  of  Sobotta,  already  alluded  to.  Although  his  studies  were  made 
entirely  upon  lower  animals,  some  of  his  results  are  without  question  appli- 
cable to  human  beings.  Sobotta's  work  has  been  confirmed  on  many  types 
of  mammalian  animals  by  Honore,  Cohn,  Bonnet,  Van  der  Stricht,  Corner, 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD       59 

Marshall  and  others.  Certainly,  speaking  from  analogy,  one  would  expect 
that  in  human  beings  also  the  lutein  cell  is  of  epithelial  origin. 

Arguing  against  a  connective  origin  of  the  cells,  Sobotta  shows  that  the 
granulosa  cells  do  not  undergo  degeneration,  and  that  as  a  matter  of  fact 
they  exhibit  signs  of  active  proliferative  activity,  and  that  there  is  a  gradual 
growth  of  connective  tissue  fibrils  and  capillaries  from  the  theca  folliculi 
pushing  over  into  the  membrana  granulosa. 

The  development  of  actual  lutein  cells  from  the  theca  interna  of  atretic 
follicles  is  denied  by  Schroder  and  others,  in  spite  of  the  similarity  in  appear- 
ance of  cells  arising  from  this  source  to  genuine  lutein  cells.  This  point  is 
emphasized  in  the  classification  given  by  Cohn  of  lutein  cells,  i.  e.,  (i) 
granulosa  lutein  cells;  (2)  theca  lutein  cells;  and  (3)  stroma  lutein  cells. 

The  recent  exhaustive  studies  of  Miller  also  bring  much  evidence  in  favor 
of  the  epithelial  genesis  of  the  lutein  cells.  By  careful  methods  of  staining 
he  concludes  that  the  finding  of  colloid  droplets  in  the  lutein  cells  of  the 
corpus  luteum  of  pregnancy  and  the  absence  of  cplloid  from  the  theca 
interna  lutein  cells  proves  the  epithelial  origin  of  the  former,  inasmuch  as 
colloid  is  just  as  distinctive  of  epithelial  tissue  as  hyalin  is  of  connective 
tissue. 

The  principal  obstacle  to  a  complete  study  of  the  life  history  of  the  corpus 
luteum,  and  therefore  of  the  origin  of  the  lutein  cells,  has  been  the  rapidity 
with  which  the  early  changes  take  place.  Sobotta,  for  example,  states  that 
the  structure  of  the  human  corpus  luteum  is  complete  about  eight  days  after 
the  rupture  of  the  follicle.  The  finding  of  a  very  early  corpus  luteum,  say 
only  a  few  hours  old,  must  therefore  be  a  very  rare  occurrence.  Such  a 
structure  would  throw  much  light  on  the  question  we  are  now  discussing. 
Interest  attaches,  especially,  to  the  study  of  such  early  corpora  lutea.  The 
first  reliable  description  of  such  a  structure  was  given  by  Robert  Meyer,  who 
thus  supplied  the  "  missing  link  "  between  the  granulosa  cell  and  the  lutein 
cell.  His  description  of  an  actual  transformation  of  granulosa  cells  into 
lutein  cells,  if  sufficiently  confirmed  by  later  studies,  would  make  the  evidence 
of  an  epithelial  origin  of  the  lutein  cells  incontrovertible.  I  believe  that 
this  evidence  is  furnished  by  the  results  of  a  study  of  five  early  corpora  lutea 
by  myself,  as  reported  in  a  recent  paper. 

All  of  the  five  specimens  were  alike  in  the  very  important  particular  that 
in  all  of  them  the  epithelial  cells  of  the  granulosa  were,  to  say  the  least, 
quite  intact.  This  fact  is  of  prime  importance  in  the  consideration  of  the 
origin  of  the  lutein  cells.  One  of  the  strongest  arguments  against  the 
epithelial  origin  of  these  cells  has  been  the  alleged  degeneration  and  disap- 
pearance of  the  membrana  granulosa  after  rupture  of  the  follicle.  In  each 
of  my  five  specimens,  however,  the  epithelium  was  well  preserved.  More- 
over, in  two  of  them  it  exhibited  definite  signs  of  lutein-like  transformation. 
This  I  look  on  as  a  vital  point  —  the  vital  point  —  in  connection  with  the 
question  of  the  origin  of  the  lutein  cell.  If  we  can  demonstrate  in  human 
beings,  as  Sobotta  seems  to  have  shown  in  lower  animals,  that  there  is  3 


60  MENSTRUATION  AND  ITS  DISORDERS 

direct  transformation  of  the  granulosa  cell  into  the  lutein  cell,  the  problem 
is  solved.  I  believe  that  Figures  12,  13,  and  14  illustrate  such  a  beginning 
transition  of  the  granulosa  cell  to  the  lutein  cell.  It  will  be  noted  that  this 
transformation  is  already  well  under  way  before  there  is  any  evidence  of 
vascular  invasion  of  the  granulosa  layer,  and  that  as  the  granulosa  cells 
assume  lutein  characteristics,  the  cells  of  the  theca  become  less  conspicuous, 
giving  up  much  of  their  fatty  content.  This  may  be  observed  from  a  com- 
parison of  Figures  12  and  14.  From  this  it  may  be  inferred  that  the  theca 
cells,  with  their  rich  fatty  content,  fulfil  an  important  nutritive  function,  as 
Meyer  has  suggested.  The  gradual  retrogression  of  the  theca  cells,  more- 
over, is  another  indication  that  it  is  not  they  that  are  to  be  transformed  into 
lutein  cells. 

Present  Status  of  Question. —  Weighing  carefully  the  evidence  in 
favor  of  each  of  the  two  theories,  as  to  the  origin  of  the  lutein  cells,  it  would 
seem  difficult  to  avoid  the  conclusion  that  the  theory  of  epithelial  origin, 
from  the  cells  of  the  granulosa,  has  been  fairly  well  established.  The  ques- 
tion is  still  a  live  one,  however,  and  there  is  need  of  further  investigation. 
The  great  desideratum  at  present  is  the  securing  of  many  more  early  corpora 
lutea,  so  that  all  stages  may  be  studied  in  the  conversion  of  granulosa  cells 
into  lutein  cells.  Evidence  of  this  sort  is  much  more  valuable  than  any 
that  can  be  obtained  from  the  study  of  the  mature  corpus  luteum, 

THE  INTERSTITIAL  CELLS  OF  THE  OVARY 

General. —  The  advance  in  our  know^ledge  of  the  relation  of  the 
ovaries  to  the  entire  organism,  through  the  medium  of  the  internal  secre- 
tions, has  given  a  strong  impetus  to  histological  studies  of  the  ovary. 
Among  other  results  of  such  studies  may  be  mentioned  the  description  of 
the  so-called  interstitial  glands  of  the  ovary.  It  has  long  been  known  that 
the  ovaries  of  many  of  the  lower  animals  contain  cells  which  are  analogous 
to  the  so-called  interstitial  cells  of  Leydig  in  the  testicle. 

Like  the  latter  cells,  the  interstitial  cells  of  the  ovary  are  apparently  of 
connective  tissue  origin,  being  placed  interstitially  among  the  connective 
tissue,  and  having  no  connection  with  the  reproductive  cell,  the  ovum. 
These  cells  had  been  described  as  existing  in  the  ovaries  of  lower  animals  by 
Pfliiger  as  far  back  as  1863.  Various  names  were  applied  to  them  by  the 
older  writers,  such  as  "  wandering  cells,"  "  plasma  cells,"  "  kornchenzellen," 
etc.  Numerous  studies  of  these  elements,  as  existing  in  the  ovaries  of 
lower  animals,  have  been  made  by  Schroen,  His,  Waldeyer,  Born,  Tour- 
neux  and  others. 

It  is  Limon  and  Bouin,  however,  who  deserve  the  credit  for  recognizing 
the  glandular  nature  of  these  cells  and  their  probable  function  in  giving  off 
an  internal  secretion.  These  authors  bestowed  upon  these  structures  the 
name  of  "  glandes  interstitielles  de  I'ovaire,"  Bouin  having  used  this  name 
in  describing  the  interstitial  cells  in  the  ovary  of  the  frog  (rana  temporia). 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        61 


Interstitial  Cells  in  Ovaries  of  Lower  Animals. —  The  studies  of 
Limoii  upon  various  lower  animals — ^  rabbits,  rats,  mice,  guinea  pigs,  bats, 
moles,  and  hedgehogs  —  led  him  to  describe,  in  addition  to  the  follicles  and 
corpora  lutea,  a  third  epithelial  structure,  consisting  mainly  of  polygonal 
epithelioid  cells,  with  an  average  diameter  of  12  to  15  microns.  The  nuclei 
of  these  cells  are  round,  with  a  diameter  of  4  to  6  microns,  while  the  proto- 
plasm contains  many  small  vacuoles,  staining  black  with  osmic  acid.  These 
cells  are  usually  arranged  either  in  rather  compact  clumps  or  strands  several 
cells  thick,  or  in  small  hollow  collections  whose  cleft-like  lumina  are  filled 
with  fine  connective  tissue.  Sometimes,  on  the  other  hand,  the  cells  lie 
scattered  in  the  ovarian  stroma  without  any  very  definite  arrangement.    The 


Fig.  22. —  Sections  of  Ovary  of  Infant  2  Days  Old,  showing  cystic  atretic  follicles  (a) 
and  maturing  graafian  follicles  (G).     (Very  low  power). 

interstitial  cells  are  perhaps  best  studied  in  the  ovaries  of  rabbits,  in  which 
they  are  abundant. 

L,  Fraenkel  has  also  studied  the  question  of  the  occurrence  and  mor- 
phology of  the  interstitial  gland  in  the  ovaries  of  as  many  as  forty-five 
different  varieties  of  animals,  belonging  to  the  orders  of  Marsupialia,  Ungu- 
lata,  Carnivora,  Rodentia,  Insectivora,  Chiroptera  and  Simiidae.  In  addi- 
tion, from  a  study  of  a  large  number  of  human  ovaries,  he  concludes  that 
interstitial  gland  tissue  is  present  only  in  traces  in  the  ovaries  of  adult 
women,  and  that  it  bears  little  resemblance  to  the  corresponding  tissue  in 
the  lower  animals. 

Interstitial  Cells  in  Human  Ovary. —  Fraenkel's  opinion  is  opposed 
to  that  of  Wallart,  who  has  perhaps  studied  the  subject,  from  the  standpoint 


62 


MENSTRUATION  AND  ITS  DISORDERS 


of  the  human  ovary,  more  exhaustively  than  any  other  author.  After  a 
large  number  of  observations,  Wallart  is  convinced  that  interstitial  gland 
tissue  exists  in  human  ovaries,  that  it  is  most  highly  developed  and  most 
abundant  in  the  earlier  years  of  life,  up  to  the  age  of  puberty,  that  it  is  much 
increased  during  pregnancy,  and  also  to  a  less  extent  during  menstruation, 
and  that  the  formation  of  the  tissue  ceases  after  the  climacterium.     The 


Fig.  23. —  Corner  of  Atretic  Follicle,  sluiwiny  di-yt'iieration  of  epithelium   (E),  and  the 
alveolar  grouping  of  the  theca  cells   (th). 


The  two  layers  are  separated  by  the  refractile 
(High  power.) 


glashaut, "  described  first  by  Grohe. 


work  of  Seitz  confirms  the  statements  made  by  Wallart  on  the  occurrence 
of  interstitial  cells  during  pregnancy,  while  Cohn,  Meyer  and  others  of  the 
modern  German  school  arrive  at  results  in  substantial  agreement  with  those 
of  Wallart.  In  human  beings,  the  cells  corresponding  to  the  interstitial 
cells  found  in  the  ovaries  of  certain  lower  animals  are  formed  from  the  cells 
of  the  theca  interna  of  atretic   follicles.     These  cells  become   large   and 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        63 

q)ithelioid  in  appearance,  while  the  protoplasm  undergoes  a  fatty  change. 
In  the  most  marked  cases  these  modified  theca  cells  form  a  broad  zone  of 
rather  alveolar  pattern,  surrounding  the  atretic  follicle.  These  changes  are 
to  be  found  most  characteristically  in  the  ovaries  of  pregnant  women. 

Origin  of  Interstitial  Cells  from  Walls  of  Atretic  Follicle. —  The 
study  of  the  interstitial  cells  in  human  ovaries  is  intimately  bound  up  with 
the  study  of  the  process  spoken  of  as  follicular  atresia,  for  it  is  the  latter 
process  which  now  seems  to  be  quite  generally  accepted  as  responsible  for 
the  production  of  the  interstitial  cells. 

Only  a  very  small  percentage  of  the  follicles  in  the  ovary  attain  maturity, 
with  the  discharge  of  ova  and  the  development  of  corpora  lutea.     The 


Fig.   24. —  Cystic  Atretic   Follicle  Undergoing  Obliteration  (above  and  to  left). 

great  number  sooner  or  later  exhibit  the  phenomenon  of  atresia,  which  is 
characterized  by  degeneration  of  the  ovum  and  of  the  epithelial  cells  of  the 
granulosa.  I  shall  not  here  discuss  the  influence  which  brings  about  this 
arrest  in  the  development  of  the  follicles,  except  to  say  that  it  seems  to 
emanate  from  the  discharged  ovum.  The  cyst-like  cavities  resulting  front 
atresia  are  found  in  practically  all  ovaries  during  the  reproductive  period, 
and  not  infrequently  even  in  the  ovaries  of  fetuses  and  young  children. 
(Fig.  22.)  When  present  in  excessive  number,  they  give  rise  to 
the  well  known  fibrocystic  disease  of  the  ovary.  The  later  history  of  the 
cystic  atresic  follicle  Is  a  gradual  process  of  obliteration.  In  other  words, 
the  two  varieties  of  atresia  folliculi  described  by  Seitz,  the  cystic  and  oblit- 


64  MENSTRUATION  AND  ITS  DISORDERS 

erative,  are  in  reality  only  different  stages  of  the  same  process,      (Fig.  24.) 
The  theca  cells  of  the  atretic  follicle  exhibit  a  striking  change  during 
pregnancy,  giving  rise  to  the  so-called  interstitial  cells,  which  are  thus  seen 
to  be  of  connective  tissue  origin. 

The  retrogression  of  the  atretic  follicle  gives  rise  to  a  terminal  structure 
somewhat  different  from  that  left  after  the  life  history  of  the  corpus  luteum  is 
run.  i.  e,,  the  corpus  Hbrosum.  The  studies  of  Wolz  lead  her  to  believe 
that  the  theca  lutein  cells,  i.  e.,  the  interstitial  cells,  can  never  become  con- 
verted into  the  lutein  cells  of  a  corpus  luteum,  nor  can  they,  after  fulfilling 
their  own  function,  be  converted  into  stromal  connective  tissue  cells.  They 
disappear  altogether,  their  site  being  marked  by  the  hyalin  connective  tissue 
of  the  corpus  fibrosum. 

V 

LITERATURE 

Ancel  et  Bouin.     Sur  les  homologies  et  la  signification  des  glandes  a  secre- 
tion uterine  de  rovaire.     Compt.  Rend.  See.  de  Biol.,  Paris,  1909,  67, 

497- 
Aschner.     Ueber  Morphologie  und  Funktion  des  Ovariums  unter  Normalen 

und  Pathologischen  Verhaltnissen.     Arch.  f.  Gyn.,  1914,  102,  446. 
VON  Bar.     De  Ovi  MamaHum  Genesi  Epistola.     Lipsiae,  1827. 
Below.     Glandula  Lutea  und  Ovarium  in  ihren  Verhalten  zu  den  Normalen 

Physiologischen  und  Pathologischen  Vorgangen  in  Weiblichen  Organ- 

ismus.     Monats.  f.  Geb.  u.  Gyn.,  1912,  37,  679. 
Bischoff.     Entwicklungsgeschichte  der  Saugethiere  und  des  Menschen.    1842. 

Beweis  der  von  der  Begattung  Unabhangigen  Periodischen  Reifung  und 

Loslosung  der  Eier  als  der  ersten  Bedingung  ihrer  Fortpflanzung,  etc. 
Giessen,  1844. 

Bouin.     Les  deux  glandes  a  secretion  interne  de  I'ovaire,  la  glande  interstitielle 

et  le  corps  jaune.     Rev.  Med.  de  I'Est,  Paris-Nancy,  1902,  34,  465. 
Clark.     Origin,  Development,  and  Degeneration  of  the  Blood  Vessels  of  the 

Human  Ovary.     Johns  Hopkins  Hosp.  Reports,  1900,  9,  593. 
• Origin,  Growth  and  Fate  of  the  Corpus  Luteum.     Johns  Hopkins  Hosp. 

Report,  1898,  7,  181. 
CoHN.     Ueber  das  Corpus  Luteum  und  den  Atretischen  Follikel  des  Menschen 

und  deren  Cystischen  Derivate.     Arch,  f.  Gyn.,  1909,  87,  367. 
Corner.     Corpus  Luteum  of  Pregnancy,  as  it  is  in  Swine.     Publication  no. 

222,  Carnegie  Institute. 
Dalton.     On  the  Corpus  Luteum  of  Menstruation  and  Pregnancy.     Phila., 

i85i._   ... 
Frank.     Clinical  Manifestations  of  Disease  of  Glands  of  Internal  Secretions  in 

Gynecological  and  Obstetrical  Patients.     Surg.,  Gyn.  and  Obst.,  1914, 

19,  618. 
Fraenkel.     Die  Funktion  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1903,  68,  438. 

Neue  Experimente  zur  Funktion  des  Cornus  Luteum.     Arch.  f.  Gyn., 

1910,  91,  705 


ANATOMIC  CHANGES  IN  OVARY  DURING  MENSTRUAL  PERIOD        65 

Gendrin.     Traite  philosophique  de  medecine  pratique.     Paris,  1839. 

Grohe.  Ueber  den  Bau  und  das  Wachstum  des  Menschlichen  Eierstocks,  etc. 
Virchows  Archiv,  1863,  26,  271. 

Halban  und  Kohler.  Die  Beziehungen  zwischen  Corpus  Luteum  und  Men- 
struation.    Arch.  f.  Gyn.,  1914,  103,  575. 

Kreis.  Die  Entwicklung  und  Riickbildung  des  Corpus  Luteum  Spurium  beim 
Menschen.     Arch.  f.  Gyn.,  1899,  58,  411. 

I  EOPOLD.  Untersuchungen  iiber  Menstruation  und  Ovulation.  Arch.  f.  Gyn., 
1883,  21,  347. 

LiMON.  fitude  histologique  et  histogenique  de  la  glande  interstitielle  de 
Tovaire.     Nancy,  1901. 

LoEB.     The  Function  of  the  Corpus  Luteum,  etc.     Med.  Record,  19 10,  'jy, 

Ueber   die   Bedeutung  des    Corpus   Luteum    fur   die    Periodizitat   des 

Sexuellen  Zyklus  beim  Weiblichen  Saugetierorganismus.    Deutsch.  Med. 
Wchnsch.,  191 1,  37,  17. 

Marcotty.     Ueber    das    Corpus    Luteum    Menstruationis    und    das    Corpus 

Luteum  Graviditatis.     Arch.  f.  Gyn.,  1914,  103,  63. 
Meyer.     Ueber  Corpus  Luteumbildung  beim  Menschen.     Zentralb.   f.  Gyn., 

1911,35,1206. 

Ueber  die  Beziehungen  der  Eizelle  und  des  Befruchteten  Eies   zum 

Follikelapparat ;    sowie  des  Corpus  Luteum  zur  Menstruation.     Arch. 
f.  Gyn.,  1913,  100,  I. 

Ueber  Corpus  Luteum  Bildung  beim  Menschen.     Arch.  f.  Gyn.,  191 1, 

93,  354- 
Meyer  und  Ruge.     Ueber  Corpus  Luteum  Bildung  und  Menstruation  in  ihren 

Zeidichen  Zusammenhorigkeit.     Zentralb.  f.  Gyn.,  1913,  Z7^  50- 
Miller.     Ueber  Corpus  Luteumbildung  beim  Menschen.     Zentralb.  f.  Gyn., 

1911,  35,  1089. 
■     Die  Riickbildung  des  Corpus  Luteum.     Munch.  Med.  Wchnsch.,  19 10, 

57,  553- 
■ Corpus  Luteum,  Menstruation  und  Graviditat.     Arch.  f.  Gyn.,  1914,  loi, 

568. 
MuLON.     Sur  les  roles  du  corps  jaune.     Ann.  de  Gyn.  et  d'Obst,  191 7,  57, 

415- 
Negrier.     Recherches   anatomiques   et   physiologiques   sur   les  ovaires   dans 

I'espece  humaine.     Paris,  1840. 
Novak.     The  Corpus  Luteum :    its  Life  Cycle  and  its  Role  in  Menstrual  Dis- 
orders.    Jour.  A.  M.  A.,  1916,  6^,  1285. 
Prenant.      De  la  valeur  morphologique  du  corps  jaune,  son  action  physio- 

logique  et  therepeutique  possible.     Rev.  Generale  des  Sciences,  1895. 
Prochownik.     Ein    Fall    von    Menstruatio    Praecox    mit    Sektionsbefund. 

Arch.  f.  Gyn.,  1881,  17,  330. 
Ravano.     Ueber  die  Frage  der  Eierstockstatigkeit  in  der  Schwangerschaft. 

Arch.  f.  Gyn.,  1907,  83,  586. 
Reusch.     Die  Friihstadien  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1916,  105,  26. 
Ruge.     Ueber  Ovulation,  Corpus  Luteum  und  Menstruation.     Arch.  f.  Gyn., 

1913,  100,  20. 


66  MENSTRUATION  AND  ITS  DISORDERS 

RuNGE.     Beitrag  zur  Anatomic  der  Ovarien  Neugeborener  und  Kinder  vor  der 

Pubertatszeit.     Arch.  f.  Gyn.,  1906,  80,  43. 
ScHAFFER.     Vergleichend  Histologische  Untersuchungen  iiber  die  Interstitielle 

Eierstocksdriise.     Arch.  f.  Gyn.,  191 1,  94,  491. 
Seitz.     Die   Folhkelatresie   wahrend   der   Schwangerschaft.     Arch.    f.    Gyn., 

1906,  -jj,  203. 

WiNTZ  UND  FiNGERHUT.     Ucbcr  die  Biologische  Funktion  des  Corpus 

Luteums.     Miinch.  Med.  Wchnsch.,  1914,  56,  1657. 
Skrobansky.     Beitrage  zur  Kentniss  der  Oogenese  bei  Saugetieren.     Arch.  f. 

Mikr.  Anat.,  1903,  62,  697. 
SoBQTTA.     Ueber  die  Bildung  des  Corpus  Luteum  bei  der  Maus.    Arch.  f.  Mikr, 

Anat,  1896,  47,  261. 
SoHMA.     Histologic  der  Ovarialgefasse,  etc.     Arch.  f.  Gyn.,  1908,  84,  377. 
Spiegelberg.     Ueber  die  Bildung  und  Bedeutung  des  Gelben  Korpers  im  Eier- 

stock.     Monats  f.  Geb.  u.  Frauenkrankh.,  1865,  26,  (quoted  by  Kreis). 
Van  Meerdervoort.     Die  Normalen  und  die  Menstruierende  Gebarmutter- 

schleimhaut.     Inaug.  Diss.,  Freiburg,  1894-5. 
Waldeyer,     Eierstock  und  Ei.     1870. 
Wallart.      Untersuchungen    iiber    die    Interstitielle    Eierstocksdriise    beim 

Menschen.     Arch.  f.  Gyn.,  1907,  81,  271. 

Untersuchungen  iiber  das  Corpus  Luteum  und  die  Interstitielle  Eier- 
stocksdriise wahrend  der  Schwangerschaft.  Zeitschr.  f.  Geb.  u.  Gyn., 
1908,  63,  520. 

Studien  iiber  die  Nerven  des  Eierstocks,  etc.     Zeitsch.  f.  Geb.  u.  Gyn., 

1915,  76,  321. 
.     Ueber  Friihstadien  und  Abortivformen  der  Corpus  Luteum  Bildung. 

Arch.  f.  Gyn.,  1914,  103,  544. 
VON  Winiwarter.     Recherches  sur  I'ovogenese  de  I'ovaire  des  mammiferes. 

Arch,  de  Biol.,  1901,  17,  33. 
WoLZ,     Untersuchungen    zur    Morphologic    der    Interstitiellen    Eiserstocks- 

driisen  des  Menschen.     Arch.  f.  Gyn.,  1912,  97,  131. 


CHAPTER  VI 
HISTORICAL  SKETCH  OF  OLDER  THEORIES  OF  MENSTRUATION 

Introduction. —  Innumerable  hypotheses  have  from  time  to  time 
been  offered  to  explain  the  occurrence  of  menstruation.  A  few  of  the 
earliest  views  on  the  subject  have  already  been  described  in  Chapter  I.  The 
older  theories  of  menstruation  now  possess  only  a  historic  interest,  but  a 
brief  review  of  the  more  important  among  them  may  be  of  interest  as  illus- 
trating the  evolution  of  our  knowledge  of  the  cause,  nature,  and  mechanism 
of  the  menstrual  process. 

The  Earliest  Theories  of  Menstruation. —  The  three  factors  variously 
considered  by  the  earliest  writers  to  be  responsible  for  the  occurrence  of  the 
menstrual  flow  were  (i)  the  influence  of  the  moon,  (2)  the  action  of  a 
"ferment"  circulating  in  the  blood,  (3)  the  condition  of  plethora,  which 
was  held  to  exist  in  all  women. 

Thf:  Theory  of  Lunar  Influence. —  The  so-called  lunar  theory  has 
already  been  discussed  in  Chapter  I. 

The  Ferment  Theory  —  The  "  Fervor  Uterinus  "  of  Democritus. 
—  Not  a  few  of  the  early  writers,  to  quote  Freind,  "  deduce  the  course  of 
the  Menstrua  from  a  certain  Ferment ;  which  indeed,  though  it  be  clouded 
by  another  word,  is  the  same  as  the  Fervor  Uterinus  of  Democritus.  They 
imagine  indeed  the  monthly  Colluvies  to  be  purged  off  at  the  Uterus  by  the 
means  of  a  Ferment,  which  de  Graaf  thinks  diffused  thro'  the  whole  Mass 
of  Blood,  but  Boyle  asserts  it  to  be  peculiar  to  the  Uterus.  They  both 
pretend  that  this  Ferment  is  seated  in  some  certain  Salts,  which  by  their 
Motion  so  exagitate  the  Mass  of  Blood,  that  at  some  certain  Season,  namely, 
every  Month,  it  is  thrown  into  a  vehement  Effervescence,  and  seeks  a 
Passage  by  the  uterine  Vessels." 

The  Plethora  Theory  of  Galen. —  Galen,  in  his  Book  of  Bleeding 
against  Erasistratus,  attributes  the  menstrual  discharge  to  a  condition  of 
plethora.  "  Does  not "  he  says  "  Nature  herself  cause  an  Evacuation  in 
all  Women,  by  throwing  forth  every  Month  the  superfluous  Blood?  I 
imagine  that  the  Female  Sex,  inasmuch  as  they  heap  up  a  great  quantity  of 
Humors,  by  living  continually  at  home,  and  not  being  used  to  hard  Labour, 
or  exposed  to  the  Sun,  should  receive  a  discharge  of  this  Fulness,  as  a 
remedy  given  by  Nature."  Freind,  like  many  others  of  his  era,  was  a  firm 
believer  in  this  doctrine,  and  he  devoted  many  pages  of  his  "  Emmenologia  " 
to  ponderous  arguments  in  its  behalf.     He  shows  very  clearly,  to  his  own 

67 


68  MENSTRUATION  AND  ITS  DISORDERS 

satisfaction  at  least,  that  plethora  exists  in  all  women,  and  that  this  is  in 
large  measure  due  to  the  fact  that  perspiration  is  less  in  women.  It  is  of 
interest  to  note  that  this  plethora  theory  of  Galen  held  sway  among  medical 
men  even  up  to  about  the  middle  of  the  last  century. 

The  Theory  of  Pfliiger. —  The  beginning  of  our  modern  knowledge 
of  the  subject  may  be  traced  from  the  discovery  by  Negrier,  in  1832,  that 
the  ovary  is  in  some  way  associated  with  the  occurrence  of  menstruation, 
although  it  was  not  until  1840  that  Gendrin  asserted  the  dependence  of  men- 
struation upon  ovulation.  The  best  known  of  the  more  modern  theories  of 
menstruation  was  that  of  Pfliiger,  who  believed  that  the  occurrence  of  men- 
struation is  the  direct  result  of  the  ripening  of  a  graafian  follicle  at  that 
time.  The  gradual  distention  of  the  substance  of  the  ovary,  as  the  follicle 
grows  larger  and  larger,  sets  up  an  irritation  of  the  ovarian  nerve.  The 
reflex  irritation  thus  brought  about  is  exerted  especially  upon  the  spermatic 
or  utero-ovarian  arteries,  so  that  they  exhibit  an  active  dilatation.  This 
produces  pelvic  congestion  and  an  increased  blood  pressure,  together  with 
the  other  symptoms  associated  with  menstruation.  As  a  result  of  the 
hyperemia  in  the  pelvis,  there  occurs  a  thickening  of  the  endometrium, 
epithelial  and  gland  proliferation,  and  finally  rupture  of  the  blood  vessels 
with  escape  of  the  blood.  An  effort  to  substantiate  this  theory  was  made 
by  Strassman,  who  endeavored  to  simulate  ripening  of  the  follicle  by  inject- 
ing sterile  water  into  the  substance  of  the  ovary.  His  work,  however,  was 
not  by  any  means  conclusive.  Although  the  theory  of  Pfliiger  retained 
much  of  its  popularity  up  to  quite  recent  years,  it  has  now  been  generally 
discarded. 

The  "  Tubal  Nerve  "  of  Tait. —  The  same  may  be  said  of  the  theory 
of  Lawson  Tait,  who  attributed  menstruation  to  the  presence  of  the  so-called 
tubal  nerve.  He  stated  that  removal  of  the  tubes,  the  ovary  being  left 
behind,  is  followed  in  ninety-five  per  cent  of  the  cases  by  cessation  of  the 
menses.  This  is  obviously  incorrect,  and  the  theory  of  Tait  now  possesses 
only  a  historic  interest. 

The  Influence  of  the  Vertical  Position  in  Causing  Menstruation. — 
An  interesting  and  quite  elaborate  theory  advanced  by  Johnstone,  which  was 
in  high  favor  for  some  years,  is  that  the  occurrence  of  menstruation  in 
human  beings  is  explainable  by  the  erect  position,  in  contradistinction  to  the 
horizontal  position  of  most  of  the  lower  animals.  No  horizontal  animals 
menstruate ;  all  vertical  animals  do.  The  os  uteri  of  the  horizontal  animal 
points  upward  and  the  other  end  of  the  uterus  points  downward.  This 
makes  it  impossible  for  such  a  uterus  to  drain  itself  through  the  cervix,  as 
is  the  case  in  the  vertical  animal.  Among  other  things  Johnstone  believed 
that  the  lymphatics  of  the  normal  endometrium  in  animals  are  not  suffi- 
ciently developed  to  absorb  the  decidua  of  menstruation,  which  must,  there- 
fore, be  expelled  into  the  vagina  like  the  decidua  of  pregnancy.  Johnstone 
states  that  in  the  ordinary  acceptation  of  the  term  the  endometrium  above 
the  internal  os  is  not  a  mucous  membrane,  but  that  it  belongs  to  the  so-called 


HISTORICAL  SKETCH  OF  OLDER  THEORIES  OF  MENSTRUATION      69 

adenoid  tissues,  and  that  menstruation  is  for  it  exactly  what  the  lymph 
stream  is  to  lymph  glands  and  the  blood  stream  for  the  spleen.  He  agrees 
with  those  who  do  not  believe  that  ovulation  and  menstruation  are  dependent 
upon  each  other,  nor  does  he  believe  that  menstruation  in  the  human  female 
is  either  homologous  or  analogous  to  the  estrus  of  the  lower  animals. 
Being  convinced  of  the  adenoid  nature  of  the  endometrium,  he  states  that 
"  the  tissue  then  belongs  to  that  class  of  organs  whose  function  it  is  to 
replace  the  organic  waste  and  that  it  ought  to  be  ranked  with  the  spleen  and 
thymus  gland  instead  of  the  vagina  and  bladder." 

Menstruation  as  a  Result  of  the  Sexual  Appetite. —  The  theory  of 
Beigel  and  others  was  that  "  ovulation  and  menstruation  are  in  no  sense 
dependent  one  on  the  other,  but  are  both  the  result  of  the  sexual  appetite." 
Of  the  arguments  against  this  theory  may  be  stated :  Firstly,  menstruation 
is  periodic  in  occurrence,  sexual  feeling  is  not ;  secondly,  congenital  absence 
of  the  ovary  necessitates  absence  of  menstruation,  and  yet  sexlial  feeling 
may  remain;  thirdly,  removal  of  the  ovaries  ordinarily  is  followed  by  ces- 
sation of  menstruation,  while  sexual  feeling  often  remains  undiminished. 

"  Women  Menstruate  Because  They  Do  Not  Conceive."  —  The  view 
originally  put  forth  by  Sigismund,  and  later  adopted  by  His,  was  that  the 
growth  stage  of  menstruation  prepares  a  bed  for  the  fertilized  ovum  and 
that  the  degeneration  stage  of  menstruation  is  to  be  looked  upon  as  a  retro- 
gression, taking  place  because  such  an  ovum  is  not  present.  This  idea  was 
expressed  by  Powers  in  the  well  known  dictum,  "  women  menstruate  because 
they  do  not  conceive."  It  is  evident  that,  according  to  this  theory,  ovula- 
tion must  take  place  prior  to  menstruation  —  a  view  which,  as  we  shall  see, 
is  in  harmony  with  our  modern  theory.  Somewhat  different  is  the  theory 
of  Geddes  and  Thomson,  according  to  which  "  the  process  is  viewed  as  a 
kind  of  cleansing  process  of  the  uterus  for  the  reception  of  the  ovum, 
whereby  the  latter  during  the  healing  process  can  be  attached  safely  to  the 
uterine  wall." 

Menstruation  an  "Unnatural  Process." — A  rather  grotesque  view, 
put  forth  in  1876  by  the  late  Dr.  A.  F.  A.  King,  of  Washington,  was  to  the 
effect  that  the  process  of  menstruation  is  not  a  physiological  one,  being  the 
result,  as  he  says,  of  an  interference  with  nature,  of  a  thwarting  of  her 
designs,  and  a  violation  of  her  laws.  He  states  that  menstruation  is  a 
hemorrhage,  being  attended  with  the  rupture  of  the  blood  vessels.  Blood 
vessels  are  not  made  to  rupture,  and  no  hemorrhage  is  natural.  Therefore 
menstruation  is  unnatural.  He  stated,  furthermore,  that  evidence  is  want- 
ing to  prove  that  menstruation  is  common  in  women  belonging  to  the  savage 
races  of  mankind  who  live  more  strictly  in  accordance  with  nature,  unham- 
pered in  their  reproductive  function  by  the  usages  of  civilization.  The 
Hindoo  women  as  a  rule,  he  said,  do  not  menstruate.  With  them  men- 
struation is  considered  a  crime.  History,  according  to  King,  does  not 
furnish  unequivocal  evidence  that  menstruation  was  common  in  ancient 
times,  and  he  quoted  the  Scriptures  in  proof  of  this  statement. 


70  MENSTRUATION  AND  ITS  DISORDERS 

Menstruation  as  a  True  Secretory  Process. —  A  comparatively  recent 
article  by  James  Oliver  ( 1906)  embodies  a  new  conception  of  the  menstrual 
process.  This  author  believes  that  menstruation  must  be  looked  upon  as 
a  definite  secretory  process  on  the  part  of  the  endometrium.  He  states,  for 
example,  that  the  menstrual  process  often  makes  its  appearance  while  the 
individual  is  asleep  in  the  recumbent  position.  The  amount  of  blood  then 
lost  is  not  materially  different  from  that  lost  by  the  same  individual  when 
the  discharge  appears  during  active  locomotion.  It  is  noteworthy,  he  says, 
that  female  acrobats  and  contortionists  engaged  actively  in  their  pursuits 
lose  no  more  than  other  women.  Again,  the  increase  of  blood  to  the 
generative  organs  caused  by  sexual  excitation  does  not  disturb  the  tenor 
of  menstruation  unless  perhaps  this  influence  is  exerted  when  the  function 
is  actually  in  existence.  When  the  menstrual  discharge  is  retained  in  cases 
of  imperforate  hymen  or  other  obstruction,  menstruation  still  takes  place 
month  after  month,  until  perhaps  several  pints  of  fluid  have  accumulated. 
It  is  practically  impossible  to  conceive  that  this  could  take  place  purely  and 
simply  from  capillary  rupture,  since  this  is  a  relatively  feeble  cause  and 
would  be  soon  annulled.  Accumulation  of  the  menstrual  blood  to  this 
extent,  however,  is  compatible  with  the  theory  of  secretion,  for  secretory 
pressure  is  a  powerful  force.  Again,  worry  often  causes  a  menstrual  dis- 
charge to  appear  before  its  time,  and  mental  shock  experienced  during  men- 
struation may  suddenly  arrest  the  flow  and  hold  it  in  abeyance,  not  only 
during  the  remainder  of  this  period,  but  for  one  or  two  months  thereafter. 
If  the  denudation  theory  of  menstruation  is  maintained,  these  movements  of 
the  uterus  are  inexplicable ;  if,  however,  the  menstrual  fluid  is  an  excretion, 
then  the  behavior  of  the  uterus  becomes  more  intelligible.  For  these  and 
other  reasons,  Oliver  suggests  that  menstruation  should  be  looked  upon  as 
a  secretory  process  on  the  part  of  the  uterine  mucosa. 

The  Theory  of  a  Menstrual  Centre. —  The  essential  features  of  this 
theory  are  as  follows :  First,  the  belief  that  a  menstrual  centre  is  situated 
in  the  lumbar  enlargement  of  the  cord ;  second,  that  menstruation  is  a  result 
of  rhythmical  changes  in  this  centre;  third,  that  menstruation  follows  the 
discharge  of  vasodilator  impulses  from  the  centre,  coursing  along  the  uterine 
nerves  to  the  uterus.  Aside  from  the  question  of  whether  or  not  the  pelvic 
neives  carry  vasodilator  fibers,  we  must  bear  in  mind  that,  as  a  rule, 
functional  hyperemia  is  produced  by  an  inhibition  of  the  normal  tonic 
vasoconstriction  of  the  blood  vessels  concerned.  This  theory,  as  usually 
stated,  embodies  the  idea  that  the  menstrual  centre  is  an  automatic  one, 
which  in  itself  is  very  improbable,  inasmuch  as  all  the  other  centres  of  which 
we  have  knowledge,  those  of  micturition  and  defecation,  for  example,  are 
reflex  in  their  nature.  Needless  to  say,  the  centre  governing  menstruation 
has  not  as  yet  been  definitely  located. 

Steps  Leading  to  the  Modern  Conception  of  Menstruation. —  Goltz's 
experiments  (1874),  since  confirmed  by  Sherrington  and  also  by  Marshall 
and  Jolly  (1905),  showed  that  "heat"  is  not  caused  by  a  cerebral  reflex. 


HISTORICAL  SKETCH  OF  OLDER  THEORIES  OP^  MENSTRUATION      71- 

In  one  case  the  spinal  cord  of  a  bitch  was  cut  at  a  point  in  the  lumbar  region. 
Normal  pro-estrum,  followed  by  estrus  and  conception,  occurred  subse- 
quently, and  pups  were  born  after  a  full  time  pregnancy.  In  another  experi- 
ment of  Goltz  and  Ewald  (1896),  the  lumbar  part  of  the  spinal  cord  was 
completely  removed  from  a  bitch,  which  afterwards  came  "  in  heat "  and 
had  pups  as  in  the  former  case,  thus  showing  that  "  heat  "  is  not  due  to  a 
spinal  reflex. 

The  transplantation  experiments  of  Marshall  and  Jolly,  Knauer  and 
Halban,  show  even  more  conclusively  that  the  connection  between  the  ovary 
and  uterus  is  not  a  nervous  one,  inasmuch  as  "  heat  "  reappeared  after 
removal  of  the  ovaries  and  their  transplantation  to  some  other  portion  of 
the  body.  Since  all  normal  nerve  connections  of  the  ovary  were  thereby 
completely  severed,  the  influence  of  the  latter  on  the  uterus  must  necessarily 
have  been  exerted  through  the  blood  stream. 

These  observations,  therefore,  bring  us  to  the  last  big  step  which  has  been 
taken  in  our  rapidly  advancing  knowledge  of  menstrual  physiology  —  the 
step  which  has  been  made  possible  only  by  the  light  of  the  hormone  theory. 
The  essential  feature  of  the  modern  theory  of  menstruation,  as  will  be  shown 
in  the  next  chapter,  is  the  view  that  the  underlying  cause  of  menstruation  is 
an  internal  secretion  or  hormone  originating  in  the  ovary. 


VI 
LITERATURE 

Beigel.     Die  Krankheiten  des  Weiblichen  Geschlechts.     Erlangen,  1874. 

Collins.  Nervous  Impulses  Controlling  Menstruation  and  Uterine  Hemor- 
rhage.   Amer.  Gyn.  and  Obst.  J.,  1895,  6,  193. 

Freind.     Emmenologia.     London,  1729. 

Geddes  and  Thomson.     Evolution  of  Sex.     London,  1889,  1890. 

Goltz.    Quoted  by  Marshall  (loc.  cit.). 

Goltz  und  Ewald.  Der  Hund  mit  Verkiirtzten  Riickenmark.  Pfliigers 
Archiv.,  1896,  63,  362. 

His.     Anatomic  Menschlichen  Embryonen.     1880. 

Johnstone.     Comparative  Zoology  of  Menstruation.     Lancet-Clinic,  Cincin., 

1897,  39,  587. 
Krieger.    Die  Menstruation.    Berlin,  1869. 
Marshall.     The  Comparative  physiology  of  Menstruation.     Internat.  Clin., 

1907,  2,  190. 
Oliver.     Some   Considerations   Concerning  Menstruation.     Lancet,    1906,  2, 

1684. 
Pfluger.     Ueber  die  Bedeutung  und  Ursache  der  Menstruation.     Berlin,  1865. 
Robinson.     Automatic  Menstrual  Ganglia;  a  New  Theory  of  Menstruation. 

N.  Y.  Med.  J.,  1891,  53,  93. 
Pinard.     La  menstruation  dans  ses  rapports  avec  Tallaitement.     Annal.  de 

Gyn.  et  d'  Obst.,  1909,  6,  721. 


n  MENSTRUATION  AND  ITS  DISORDERS 

SiGiSMUND.  Ideen  iiber  das  Wesen  der  Menstruation.  Berl.  Klin.  Woch- 
ensch.,  1871,  8,  624. 

Strassman.  Beitrage  zur  Lehre  von  der  Ovulation,  Menstruation,  und  Con- 
ception.   Arch.  f.  Gyn.,  1896,  52,  134 

Tait.    Menstruation  and  the  Ovaries.    Lancet,  1888,  2,  1044. 

WiNTERHALTER.  Ein  Sympathisclies  Ganglion  in  Menschlichen  Ovarium,  etc. 
Arch.  f.  Gyn.,  1896,  51,  49. 


CHAPTER  VII 

THE  MODERN  THEORY  OF  MENSTRUATION 

The  Ovary  the  Underlying  Cause  o£  Menstruation. —  Our  modern 
conception  of  the  mechanism  of  menstruation  is  based  upon  the  behef  that 
the  ovary  gives  forth  an  internal  secretion,  which  is  responsible  for  the 
phenomenon.  As  we  shall  see,  there  are  some  who  take  exception  to  this 
theory,  but  the  evidence  in  its  favor  seems  quite  overwhelming.  The  cessa- 
tion of  menstruation  after  castration,  the  reappearance  of  menstruation  after 
successful  transplantation  of  the  ovaries,  and  the  occasional  appearance  of 
menstruation  after  administration  of  ovarian  extracts  of  one  form  or 
another,  all  speak  for  the  essential  importance  of  the  ovary  in  menstruation. 

Halban  has  brought  forth  evidence,  both  clinical  and  experimental,  indi- 
cating that  the  ovaries  are  not  quite  as  essential  in  the  causation  of  men- 
struation as  we  have  been  accustomed  to  believe,  and  that  they  are  rather  to 
be  looked  upon  as  activators  of  the  real  underlying  cause,  which  probably  has 
its  source  elsewhere  in  the  ductless  gland  chain.  The  interrelation  of  the 
various  internal  secretory  structures  has  long  been  known,  however,  and 
nothing  in  Halban's  work  disproves  the  view  that,  directly  or  indirectly,  the 
presence  of  the  ovary  is  necessary  for  the  occurrence  of  menstruation. 

The  Ovarian  Influence  Exerted  through  Blood  Stream,  and  not 
BY  Nerves. —  For  many  years,  since  1832,  the  occurrence  of  the  menstrual 
phenomenon  has  been  attributed  to  the  activity  of  the  ovaries.  This  is 
exemplified  in  the  theory  of  Pfliiger,  which  was  in  such  vogue  until  com- 
paratively recent  years,  and  which  explained  menstruation  as  due  to  a  ner- 
vous reflex  evoked  by  the  ripening  of  the  graafian  follicle.  In  other  words, 
the  impulse  originating  from  the  ovary  was  believed  to  reach  the  uterus 
through  the  medium  of  nerve  channels. 

This  belief  was  shown  to  be  incorrect  by  the  striking  transplantation 
experiments  of  such  investigators  as  Marshall  and  Jolly,  Knauer,  Halban 
and  others.  These  authors  demonstrated  that  menstruation  persists  even 
after  complete  removal  of  both  ovaries  —  and  of  course  severance  of  their 
nerve  communications  —  if  they  be  successfully  transplanted  to  some -other 
portion  of  the  body,  perhaps  quite  distant  from  their  normal  site.  In  other 
words,  the  impulse  responsible  for  menstruation  must  originate  in  the 
ovaries,  and,  just  as  obviously,  must  travel  by  way  of  the  blood  stream. 
It  is  therefore  to  be  classed  among  the  internal  secretions  or  hormones  of 
the  body. 

7Z 


74  MENSTRUATION  AND  ITS  DISORDERS 

Which  Constituent  of  the  Ovary  is  Concerned  with  Menstrua- 
tion?—  There  has  been  much  discussion  as  to  just  which  element  in  the 
structure  of  the  ovary  is  concerned  in  the  production  of  this  important 
hormone.  Is  it  the  follicle,  the  stroma,  or  the  corpus  luteum?  More  and 
more  the  evidence  is  pointing  to  the  corpus  luteum  as  the  structure  primarily 
and  perhaps  exclusively  filling  this  role.  The  father  of  this  theory  was 
Gustav  Born,  who  bequeathed  his  ideas  to  his  pupil  Fraenkel,  by  whom 
they  were  placed  upon  an  experimental  basis. 

The  Corpus  Luteum  Theory  of  Fraenkel. —  Fraenkel's  hypothesis  in 
regard  to  the  underlying  cause  of  menstruation  is  only  a  part  of  his  larger 
theory  as  to  the  part  played  by  the  corpus  luteum  throughout  the  entire 
reproductive  period.  He  believes,  first  of  all,  that  the  corpus  luteum  must 
be  looked  upon  as  a  ductless  gland,  which  is  renewed  every  four  weeks 
during  the  sexual  life  of  the  human  female,  and  at  different  periods  in  the 
various  lower  animals.  Broadly  speaking,  it  might  be  said  that  there  is  only 
one  corpus  luteum,  which  is  regenerated  periodically  and  which  occupies 
different  positions  in  the  same  or  other  ovary. 

Its  function  is  to  maintain  the  nutrition  of  the  uterus  from  puberty  to  the 
menopause  and  to  prepare  its  mucosa  for  the  reception  and  maintenance  of 
the  ovum.  If  the  latter  be  fertilized,  the  corpus  luteum  is  important  in  the 
fixation  of  the  ovum  and  its  nutrition  during  the  early  months  of  the  preg- 
nancy. If,  on  the  other  hand,  the  ovum  escape  fertilization,  there  is  a 
retrogression  of  the  hyperemia  produced  by  the  corpus  luteum,  which  under- 
goes degeneration  until  it  is,  so  to  speak,  renewed  in  a  fresh  position. 
Fraenkel's  views  were  based  primarily  upon  the  study  of  nine  operative  cases 
in  which  the  corpus  luteum  was  destroyed  by  the  actual  cautery.  In  eight 
of  these  the  succeeding  menstruation  was  said  to  have  been  missed.  A  later 
paper  is  based  upon  a  much  larger  material. 

Other  Modern  Views  of  the  Cause  of  Menstruation. —  Theory  of 
Marshall. —  Marshall  does  not  accept  the  findings  of  Fraenkel.  Although 
he  believes  that  the  ovary  provides  an  internal  secretion,  he  considers  that 
this  is  elaborated  by  the  follicular  epithelial  cells  or  the  stroma  rather  than 
by  the  corpora  lutea.  This  secretion  circulates  in  the  blood  and  produces  a 
series  of  changes,  which  at  least  assist  in  the  phenomena  of  heat  or  of 
menstruation.  After  ovulation,  which  occurs  normally  in  the  lower  animals 
during  estrus,  the  corpus  luteum  is  formed,  and  this  organ  elaborates  a 
further  secretion,  the  presence  of  which  is  essential  for  the  changes  taking 
place  during  the  attachment  and  development  of  the  embryo  in  the  first 
stages  of  pregnancy.  Marshall  suggests,  from  these  conclusions,  that  the 
effect  produced  by  the  administration  of  ovarian  extract  must  vary  accord- 
ing to  the  condition  (whether  estrous,  non-estrous,  or  pregnant)  of  the 
animal  from  which  the  extract  is  obtained. 

Theory  of  Theilhaber. —  Theilhaber,  also,  disagrees  with  Fraenkel  as 
to  the  role  of  the  corpora  lutea  in  the  origin  of  menstruation.  He  says  that 
the  internal  secretion  which  causes  menstruation  is  produced  by  the  ripening 


THE  MODERN  THEORY  OF  MENSTRUATION  75 

of  the  ovum.  The  farther  it  is  removed  from  maturation,  the  less  of  such 
secretion  does  the  egg"  contain,  and  vice  versa.  If  the  unimpregnated  e.gg  is 
thrown  off,  there  is,  for  a  few  weeks,  a  deficiency  of  this  secretion,  and  the 
hyperemia  of  the  uterus  subsides.  As  soon,  however,  as  a  ripening  ovum 
again  produces  larger  quantities,  the  amount  of  blood  in  the  uterus  is  decid- 
edly increased.  This  explains  the  cyclic  nature  of  menstruation.  If  the 
ovum  is  impregnated,  it  remains  in  the  organism  and  menstrual  hyperemia 
persists.  By  the  penetration  of  the  spermatozoa  into  the  egg,  the  formation 
of  the  secretions  by  the  egg  is  greatly  stimulated  and  a  greater  hyperemia 
of  the  generative  organs  is  quickly  produced.  This  is  especially  true  of  the 
uterus,  which  rapidly  increases  in  size  with  the  increase  of  the  ovum.  The 
ovum  itself,  so  to  speak,  regulates  the  condition  of  the  nourishment  which 
it  needs.  When  ovulation  is  scanty,  as  in  the  preclimacteric  years,  and  with 
cessation  of  ovulation,  as  in  the  postclimacteric  years,  there  occurs  gradually 
a  marked  stenosis  of  the  vessels  of  the  generative  organs  with  a  resulting 
and  permanent  anemia.  Very  little  proof  is  offered  by  Theilhaber  of  the 
truth  of  this  theory  that  the  ovum  itself  supplies  internal  secretions  which 
bring  about  menstruation. 

Studies  of  Aschner. —  Another  author  who  does  not  accept  the  theory 
of  Fraenkel  is  Aschner,  who  states  that  he  has  always  been  able  to  cause 
hyperemia  and  hemorrhage  from  the  genitalia  by  the  injection  of  ovarian 
extract,  but  never  by  the  injection  of  extract  of  corpus  luteum  alone.  He 
also  refers  to  the  work  of  Landsburg  and  Okintschitz,  who  reported  that 
corpus  luteum  extract  will  often  bring  about  cessation  of  uterine  hemor- 
rhage. 

Jnvestigations  of  Loeb. —  Perhaps  the  most  extensive  experimental 
investigations  of  the  subject  have  been  those  conducted  by  Loeb,  whose  work 
was  carried  out  principally  on  guinea  pigs.  He  believes  that  the  uterine 
cycle  in  these  animals  can  be  divided  into  two  periods.  The  first,  which 
comprises  the  changes  associated  with  heat  and  ovulation,  he  does  not 
believe  is  due  to  the  activity  of  the  corpus  luteum,  but  is  actually  inhibited 
by  it.  On  the  other  hand,  the  second  stage,  characterized  by  a  decidual 
reaction  and  by  phenomena  of  secretion  in  the  uterine  glands,  depends  upon 
the  presence  of  the  corpus  luteum.  He  wisely  adds  that  "  menstruation 
introduces  a  complication  into  the  cycle,  inasmuch  as  the  cessation  of  growth 
processes  is  followed  by  necrotic  changes  in  the  mucosa  and  by  hemor- 
rhages." 

Theory  of  Halban. —  Finally,  mention  may  be  made  of  the  work  of 
Halban,  who  also  has  energetically  opposed  the  findings  of  Fraenkel.  Like 
other  authors,  Halban  criticizes  the  methods  of  study  employed  by  Fraenkel. 
He  himself  reports  his  findings  In  forty  cases  in  which  the  corpus  luteum 
had  been  removed,  during  the  course  of  operation,  for  the  purpose  of  study- 
ing the  effect  of  the  removal  upon  menstruation.  In  Halban's  cases,  the 
removal  was  effected  by  actual  excision  of  the  entire  corpus  luteum,  whereas 
in  Fraenkel's  cases,  as  has  been  stated,  an  effort  was  made  to  destroy  the 


^^  MENSTRUATION  AND  ITS  DISORDERS 

corpora  lutea  by  means  of  the  cautery  point.  The  latter  method,  Halban 
states,  does  not  by  any  means  ensure  complete  destruction  of  all  lutein  tissue. 

In  37  of  the  40  cases  studied  by  Halban  (92.5  per  cent),  uterine  bleeding 
appeared  from  two  to  four  days  after  operation,  lasting  from  three  to  eight 
days.  Unfortunately,  no  histological  studies  of  the  uterine  mucosa  from 
these  cases  were  available  to  determine  whether  this  hemorrhage  was  a 
genuine  menstrual  flow  or  merely  a  single  postoperative  non-menstrual 
hemorrhage.  It  is  suggestive,  however,  that  in  practically  all  these  cases 
the  following  menstrual  period  appeared  four  weeks  after  this  postoperative 
bleeding,  which  would  seem  to  indicate  the  menstrual  character  of  the  latter. 
It  is  of  further  interest  to  note,  moreover,  that  the  above  described  phe- 
nomenon occurred  regardless  of  whether  the  operation  was  performed  a 
short  or  a  long  time  after  the  preceding  menstrual  period.  In  three  cases  in 
which  both  ovaries  were  completely  removed,  uterine  hemorrhage  occurred 
two  or  three  days  after  operation,  as  in  the  remainder  of  the  series.  Halban 
explains  this  as  due  to  the  fact  that  a  sufficient  amount  of  the  active  ovarian 
substance  had  made  its  way  into  the  circulation  before  the  operation  to  bring 
on  the  hemorrhage. 

Halban  deduces  from  these  observations  that  the  corpus  luteum  does  not 
cause  menstruation,  but  that  the  latter  is  due  to  ovulation.  Like  Fraenkel, 
he  believes  that  ovulation  occurs  in  the  intermenstrual  period.  The  corpus 
luteum,  according  to  him,  develops  from  the  ruptured  follicle  and  exerts  an 
inhibitory  effect  upon  menstruation  and  ovulation  both.  The  menstrual 
hemorrhage  does  not  occur  until  the  inhibitory  influence  of  the  corpus  luteum 
is  removed  by  atrophy  of  the  structure.  Ovulation  likewise  is  dependent 
upon  retrogression  of  the  corpus  luteum. 

Recent  Histological  Confirmation  of  Corpus  Luteum  Theory. — 
There  can  be  little  doubt  that  the  flaws  which  various  observers  have  picked 
in  the  methods  of  study  employed  by  Fraenkel  are  in  large  measure  justified. 
This  fact,  however,  should  not  prejudice  us  too  strongly  against  the  truth 
of  the  theory  which  he  enunciated.  It  has  received  very  strong  confirma- 
tion, during  the  past  few  years,  from  a  number  of  investigators  whose 
methods,  apparently,  leave  little  room  for  scientific  criticism.  I  refer  to  the 
work  which  originally  emanated  from  Meyer  and  Ruge,  of  Bumm's  clinic 
at  Berlin,  which  has  since  then  received  the  substantial  confirmation  of 
Miller,  Schroder  and  others. 

The  epoch  making  contributions  of  Meyer  and  others  previously  men- 
tioned to  our  knowledge  of  the  life  history  of  the  corpus  luteum  have  already 
been  discussed.  (Chapter  V.)  The  methods  of  these  investigators  were 
radically  different  from  those  of  Fraenkel.  A  large  series  of  cases  were 
utilized  by  Meyer  and  Ruge,  for  example,  in  an  effort  to  correlate  the  men- 
strual history  of  the  patient,  the  anatomic  findings  in  the  endometrium,  and 
the  histological  stage  of  development  in  the  corpus  luteum.  While  they 
differ  from  Fraenkel  as  to  the  exact  time  at  which  ovulation  occurs,  they 
agree  with  him  that  it  is  in  the  interval  between  the  menstrual  periods. 


THE  MODERN  THEORY  OF  MENSTRUATION  /7 

They  also  corroborate  his  finding  that  a  mature  corpus  luteum  is  found 
just  before  menstruation  and  they  agree  that  it  is  the  actively  functionating 
corpus  hiteum  that  is  responsible  for  the  occurrence  of  the  menstrual  phe- 
nomenon. The  life  history  of  the  corpus  luteum,  and  its  relation  to  men- 
struation, as  described  by  these  authors,  has  already  been  described  in  a 
preceding  chapter.  (Chapter  V.)  Miller,  who  has  also  made  an  extensive 
study  of  this  subject,  criticizes  some  of  the  material  utilized  by  Meyer  and 
Ruge  in  their  investigations,  but  his  own  results  are  substantially  in  agree- 
ment with  theirs. 

Especially  interesting  are  the  studies  of  Schroder  upon  the  importance  of 
the  corpus  luteum  in  menstruation.  This  investigator  asserts  that  a  young 
proliferating  corpus  luteum  can  always  be  found  with  the  first  signs  of 
secretory  activity  in  the  endometrium;  that  a  mature  corpus  luteum  is 
always  associated  with  the  premenstrual  picture  in  the  endometrium,  and 
that  the  retrogressing  corpus  luteum  is  found  with  the  "  status  intra-  or  post- 
desquamationem  mucosae."  He  states  that  ovulation  occurs  at  a  period 
corresponding  to  the  fourteenth  to  the  sixteenth  days  of  the  menstrual  cycle 
in  women  who  menstruate  regularly  every  four  weeks,  for  it  is  at  this  time 
that  the  first  signs  of  secretory  activity  appear  in  the  endometrium.  He 
looks  upon  the  parallel  developmental  cycles  of  the  corpus  luteum  and  the 
endometrium  as  strong  evidence  that  the  former  is  the  cause  of  the  menstrual 
phenomenon. 

Injection  Experiments. —  Up  to  the  present  time  no  definite  conclu- 
sions are  justified  by  the  results  of  injecting  into  animals  various  forms  of 
ovarian  extract.  Some  of  the  studies,  however,  have  been  suggestive. 
Adler,  for  example,  was  able,  by  injecting  ovarian  extract,  to  bring  about 
the  characteristic  premenstrual  swelling  of  the  endometrium.  In  human 
beings,  also,  cases  have  been  recorded  in  which  menstruation  was  apparently 
restored  by  the  subcutaneous  or  intravenous  injection  of  soluble  extract  of 
ovarian  or  corpus  luteum  extracts.  Such  observations  are,  however,  too 
few  and  too  inconstant  to  possess  much  significance. 

Conclusions  as  to  Cause  of  Menstruation. —  The  histological  studies 
above  described,  added  to  the  clinical  studies  of  Fraenkel  and  others,  speak 
strongly  in  favor  of  the  corpus  luteum  theory  of  menstruation.  The  proof, 
however,  can  not  as  yet  be  considered  absolute.  For  example,  it  is  con- 
ceivable that  the  corpus  luteum  and  endometrial  cycles,  instead  of  being 
related  as  cause  and  effect,  might  both  be  results  of  some  underlying  cause. 
The  problem,  after  all,  is  one  which  must  in  the  final  analysis  be  worked  out 
by  the  biological  chemist. 

Were  it  possible  to  isolate  the  active  hormone  of  the  corpus  luteum,  and 
by  injecting  it  Into  the  blood  to  bring  about  the  characteristic  premenstrual 
hypertrophic  changes  In  the  uterus,  the  problem  would  be  solved.  So  far, 
however,  It  has  not  been  possible  to  isolate  the  active  substance  of  the  corpus 
luteum,  and  the  results  of  Injecting  or  feeding  the  various  forms  of  corpus 
luteum  extract,  as  already  mentioned,  have  not  been  altogether  convincing. 


78  MENSTRUATION  AND  ITS  DISORDERS 

The  matter  is  complicated  by  the  fact  that  the  function  of  the  corpus  luteum 
appears  to  vary  at  different  stages  in  its  development  (Seitz).  For  the 
present,  therefore,  the  question  must  still  be  looked  upon  as  an  open  one, 
although  the  weight  of  evidence,  it  seems  to  me,  is  overwhelmingly  in  favor 
of  the  corpus  luteum  as  the  ovarian  constituent  responsible  for  the  menstrual 
phenomenon. 

Influence  of  Endocrine  Glands  Other  Than  Ovary. —  Essential  as  the 
ovary  is  to  menstruation,  it  must  not  be  forgotten  that  the  latter  function  is 
subject  to  profound  influence  by  many  other  endocrine  glands.  This  subject 
will  be  discussed  in  Chapter  XXIV.  For  the  present  we  may  merely 
emphasize  that  while  the  entire  endocrine  system  is,  in  the  broadest  sense, 
responsible  for  the  menstrual  flow,  the  ovary  exerts  by  far  the  most  direct 
influence  —  it  Is  the  portal  through  which  the  entire  ductless  gland  chain 
exerts  its  effect  upon  menstruation. 

Vascular  and  Vasomotor  Factors  in  Menstruation. —  Assuming, 
then,  that  it  is  the  ovary  which  is  primarily  responsible  for  the  menstrual 
process,  there  are  still  a  number  of  other  links  in  the  menstrual  chain  which 
demand  explanation.  Menstruation  is  pre-eminently  a  vascular  phenome- 
non, as  indicated  by  the  pelvic  hyperemia  characterizing  it. 

How  does  the  ovarian  hormone  bring  about  the  hyperemia  of  menstrua- 
tion? It  either  acts  directly  on  the  blood  vessel  walls  or  it  produces  its 
effect  through  the  vasomotor  nerves.  There  is  some  reason  for  supporting 
the  first  of  these  views,  although  the  second  manner  of  action  is  more  com- 
monly found  in  the  body.  Physiologists,  I  believe,  are  prone  to  speak  of 
any  relay  station  in  the  spinal  cord  or  elsewhere  as  a  "  center,"  and  from 
this  point  of  view  some  have  spoken  of  a  so-called  menstrual  center,  usually 
described  as  being  located  in  the  lumbar  portion  of  the  spinal  cord.  While 
there  seems  to  be  no  definite  knowledge  concerning  such  a  center,  there  is 
no  question  that  the  vasomotor  nerves  of  the  pelvis  play  an  important 
role  —  whether  essential  or  only  supplementary  we  cannot  say  —  in  the 
production  of  the  hyperemia  which  is  perhaps  the  most  conspicuous  feature 
of  menstruation.  The  vasomotor  nerves  are  offshoots  of  the  sympathetic 
nervous  system,  and  through  the  rami  communicantes  are  linked  up  with 
the  cerebrospinal  system  and  even  with  the  psychic  centers  in  the  brain. 
These  facts  are  of  practical  importance  in  explaining  certain  types  of 
abnormal  uterine  hemorrhage. 

A  Local  Factor  in  the  Endometrium. —  There  is  still  another  factor 
of  importance  which  must  be  considered  in  the  explanation  of  the  menstrual 
mechanism.  Hyperemia  of  the  uterine  or  endometrial  blood  vessels  is  not 
in  itself  sufficient  to  explain  the  exit  of  blood  elements,  especially  of  red 
blood  corpuscles,  from  the  blood  vessels  toward  and  into  the  cavity  of  the 
uterus.  Such  a  phenomenon  would  clash  with  all  our  ideas  of  the  usual 
simplicity  of  the  process  of  hyperemia.  Even  in  the  most  intense  hyperemia 
associated  with  inflammatory  processes,  there  is  no  such  wholesale  exodus 
of  red  corpuscles  from  the  blood  vessel  lumina  into  the  surrounding  tissues. 


THE  MODERN  THEORY  OF  MENSTRUATION  79 

No  consideration  of  the  physiology  of  menstruation  can  therefore  be  com- 
plete without  the  assumption  —  though  as  yet  it  is  little  more  than  an 
assumption  —  that  a  rule  of  much  importance  is  played  by  some  local  factor 
in  the  endometrium  which  in  some  way  increases  the  permeability  of  the 
blood  vessel  walls  to  the  blood  elements  of  menstruation.  According  to 
Sampson,  it  is  especially  the  small  veins  of  the  endometrium  which  give 
passage  to  these  elements.  Just  what  this  factor  is,  how  it  is  formed,  and 
how  it  acts  has  not  as  yet  been  determined.  Much  work  has  been  done  and 
is  now  being  done  in  an  effort  to  solve  this  problem,  but  so  far  the  results 
are  very  indefinite. 

This  question  is  closely  bound  up  with  the  consideration  of  why  menstrual 
blood  is  non-coagulable  (Chapter  VIII).  Whether  the  same  local  factor 
is  responsible  for  the  non-coagulability  of  the  menstrual  blood  as  well  as 
for  its  passage  through  the  vessel  walls,  and  whether  the  substance  is  a 
hormone  or  an  enzyme,  are  questions  which  cannot  as  yet  be  answered.  In 
the  final  analysis,  however,  it  seems  very  probable  that  the  formation  of  the 
substance  in  the  endometrium  is  dependent  upon  the  ovarian  function. 
Perhaps,  as  Schickele's  work  indicates,  the  substance  is  actually  formed  by 
the  ovaries  and  given  off  in  the  endometrium. 


VII 

LITERATURE 

Abler.     Zur  Physiologie  und  Pathologie  der  Ovarialfunktion.     Arch.  f.  Gyn., 

1911.  95.  391- 
Aschner.     Ueber  Brunstartige  Erscheinungen  nach  Subkutaner  Injektion  von 

Ovarial  —  oder  Plazentarextract.     Arch.  f.  Gyn.,  1913,  99,  534. 
Bell  and  Hick.     Observations  on   Physiology  of  Female   Genital  Organs. 

Brit.  Med.  Jour.,  1908,  i,  517. 
Bell.     Menstruation  and  its  Relationship  to  Calcium  Metabolism.     Proc.  Roy. 

Soc.  Med.,  1907-8,  I,  Obst.  and  Gyn.  Sect.,  291. 
Below.     Glandula  Lutea  und  Ovarium  in  Ihren  Verhalten  zu  den  Normalen 

Physiologischen  und  Pathologischen  Vorgangen  im  Weiblichen  Organ- 

ismus.     Monat.  f.  Geb.  u.  Gyn.,  1912,  36,  679. 
Brill.     Die  Histologic  des  Sympathicus  in  Ihren  Beziehungen  zur  Inneren 

Sekretion  des  Ovariums.     Miinch.  Med.  Wchnsch.,  1914,  61,  1256. 
Fraenkel.     Neue  Experimente  zur  Funktion  des  Corpus  Luteum.     Arch.  f. 

Gyn.,  1910,  91,  705. 

Die  Funktion  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1903,  68,  438. 

Gebhard.     Die  Menstruation.     Veit's  Handbuch  der  Gyn.,  1898,  3,  i. 
GoFFE.     Biochemical  Function  of  Endomterium,  etc.     N.  Y.  Med.  J.,  1914, 

100,  109. 
Halban  und  Kohler.     Die  Beziehungen  zwischen  Corpus  Luteum  und  Men- 
struation.   Arch.  f.  Gyn.,  1914,  103,  575. 
Knauer.    Die  Ovarientransplantation.     Arch.  f.  Gyn.,  1899,  68,  322. 


80  MENSTRUATION  AND  ITS  DISORDERS 

Labhardt.  Ueber  das  Verhaltnis  des  Corpus  Luteuni  zur  Menstruation. 
Zentralb.  f.  Gynak.,  1920,  44,  185. 

Lane-Claypon  and  Starling.  On  the  Origin  and  Life-History  of  the  In- 
terstitial Cells  of  the  Ovary  in  the  Rabbit.     Proc.  Roy.  Soc.  B.,  1906, 

77,  32. 
LoEB.     Relation  of  Ovary  to  Uterus  and  Mammary  Gland.     Surg.,  Gyn.  and 

Obst.,  1917,  25,  300. 

• The  Function  of  the  Corpus  Luteum.     Med.  Rec,  1910,  Jj,  1083. 

Marcotty.    Ueber  das  Corpus  Luteum  Menstruationis  und  das  Corpus  Luteum 

Graviditatis.    Arch.  f.  Gyn.,  1914,  103,  63. 
Marshall.    Physiology  of  Reproduction.    London,  1910. 
• Comparative   Physiology  of  Menstruation  and  Allied   Processes.     In- 

ternat.  Clin.,  1907,  17  s.,  2,  190. 
Meyer.     Ueber  die  Beziehung  der  Eizelle  und  des  Befruchteten  Eies  zuni 

Follikelapparat,  sowie  des  Corpus  Luteum  zur  Menstruation.     Arch. 

f.  Gyn.,  1913,  100,  I. 

UND  Ruge.     Ueber  Corpus-luteum-bildung  und  Menstruation  in  Ihren 

Zeitlichen  Zusammenhorigkeit.     Zentralb.  f.  Gyn.,  1913,  37,  50. 

Ueber  Corpus  Luteum  Bildung  beim  Menschen.     Arch.  f.  Gyn.,  191 1, 

93,  354- 
MoRAWiTZ.     Beitrage  zur  Kenntnis  der  Blutgerinnung.     Deutsches  Arch.   f. 

KHn.  Med.,  1904,  79,  i. 
MuLON.     Sur  les  roles  du  corps  jaune,  etc.     Ann.  de  Gyn.  et  d'  Obst.,  1917, 

72,  415- 
Oliver.     A  Further  Contribution  Concerning  Menstruation.     N.  Y.  Med.  J., 

1907,  85,  1 177. 
Regoud  et  Dubreuil.     Corps  jaunes,  menstruation  et  rut.     Lyon  Med.,  1909, 

112,585- 
Ruge.     Ueber  Ovulation,  Corpus  Luteum  und  Menstruation.     Arch.  f.  Gyn., 

1913,  100,  20. 
Schickele.     Wirksame  Substanzen  in  Uterus  und  Ovarium.*    Miinch.  Med. 
Wchnsch.,  191 1,  58,  123. 

Beitrage  zur  Physiologic  und  Pathologic  der  Ovarien.     Arch.  f.  Gyn., 

1912,  97,  409. 

Schroder.     Anatomische  Studien  zur  Norm.alen  und  Pathologische  Physiologic 
der  Menstruationszyklus.     Arch.  f.  Gyn.,  1915,  104,  27. 

Neue  Ansichten  iiber  die  Menstruation  und  ihrc  Zcitliches  Verhalten  zur 

Ovulation.     Monats.  f.  Geb.  u.  Gyn.,  1913,  38,  i. 

Seitz,  Wintz  und  Fingerhut.     Ueber  die  Biologische  Funktion  des  Corpus 

Luteum.     Miinch.  Med.  Wchnsch.,  1914,  61,  1657. 
Sturmdorf.     Studies  on  a  Local  Hematologic  Factor  in  the  Causation  of 

Uterine  Hemorrhage.     N.  Y.  State  J.  of  Med.,  1911,  11,  460. 
Theilhaber.     Zur   Lehre  von   der  Entstehung   der   Menstruation.     Miinch. 

Med.  Wchnsch.,  1911,  58,  465. 


CHAPTER  VIII 
CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION 

Introduction. — r  Although  menstruation  is  in  itself  a  purely  physi- 
ological phenomenon,  it  often  gives  rise  to  match  discomfort,  sometimes 
amounting  to  actual  disability.  It  is  difficult  to  draw  any  sharp  line  between 
the  mild  subjective  symptoms  experienced  by  many  women  at  this  time  and 
the  more  severe  discomfort  which  is  entitled  to  the  designation  of  dysmenor- 
rhea. In  any  consideration  of  the  symptom  of  pain,  the  personal  factor 
plays  an  all  important  part.  The  subject  is  further  complicated  by  the  well 
known  fact  that  normal  menstruation  may  occur  even  in  the  presence  of  the 
most  extensive  pathological  conditions  in  the  pelvis.  In  general,  it  may  be 
said  that  normal  menstruation  is  not  accompanied  by  actual  pain,  although 
there  is  often  a  sense  of  heaviness  and  discomfort  in  the  pelvis.  The  group 
of  subjective  symptoms  associated  with  the  occurrence  of  menstruation  is 
spoken  of  as  the  menstrual  molimina. 

Is  Pain  a  Symptom  of  Normal  Menstruation?  —  An  interesting  study 
has  been  made  by  Chisholm  of  the  menstrual  process  in  lOO  women  who 
were  earning  their  living  by  industrial,  professional  or  domestic  work.  The 
information  on  which  her  paper  is  based  was  derived  from  the  women  by 
means  of  a  questionnaire.  Since  no  pelvic  examinations  were  made,  the 
results  obtained  cannot  be  safely  taken  as  applicable  to  the  normal  woman. 
This  fact  no  doubt  explains  why  Chisholm  found  that  only  23  per  cent  of 
the  women  were  absolutely  free  from  pain  or  nervous  disturbance,  and  that 
yy  per  cent  had  some  form  of  pain  or  discomfort.  Even  in  her  series  only 
3  per  cent,  however,  had  pain  so  severe  as  to  be  sometimes  incapacitating, 
although  there  is  little  doubt  that  the  series  included  a  certain  number  of 
women  with  pathological  alterations  of  the  pelvic  organs. 

Although  yy  per  cent  of  the  patients  in  Chisholm's  series  had  some  form 
of  pelvic  discomfort,  she  points  out  that  in  45  per  cent  it  was  described  as 
occasional  or  slight,  and  a  further  12  per  cent  complained  only  of  irritability, 
melancholia,  headache,  and  such  other  nervous  symptoms. 

Chisholm  gives  the  following  table  showing  the  comparative  frequency 
with  which  pain  occurs  in  girls  and  in  adult  women : 


81 


82 


MENSTRUATION  AND  ITS  DISORDERS 

Percentage  of  Pain  Incidence 


Free  from  pain 

Occasional  slight  pain 

Slight  pain  or  discomfort 

Occasionally  or  always  severe. 
Incapacitating  at  times 


GIRLS 

ADULTS 

58.6% 

23% 

19.2% 

18% 

14.4% 

50% 

5.8% 

16% 

2.0% 

3% 

A  somewhat  similar  study  by  Marie  Tobler,  based  on  1020  cases,  gave  a 
total  of  84  per  cent  in  which  some  form  of  menstrual  disturbance  was 
experienced.  This  includes  not  only  those  in  which  pain  was  complained 
of,  but  also  those  in  which  other  physical  or  mental  symptoms  were  noted. 

Finally,  I  may  mention  the  results  of  a  study  by  Dr.  Mary  A.  Hodge  of 
974  ostensibly  healthy  girls  in  the  gymnasium  classes  of  the  Public  Athletic 
League  of  Baltimore.  For  these  figures  I  am  indebted  to  Dr.  Wm.  A. 
Burdick,  director  of  the  League.  Of  the  974  girls  studied,  660,  or  68.8 
per  cent,  suffered  no  pain  at  menstruation,  while  314,  or  31.2  per  cent, 
experienced  various  degrees  of  pain.  This  latter  group  was  subdivided 
as  follows : 

(a)  Those  with  "  occasional  slight  pain,"  numbering  78.  Setting  aside 
this  group  there  were  left  236,  or  24.1  per  cent  of  the  total  series,  with  any 
really  significant  pain. 

(b)  Those  with  "  occasional  moderate  "  or  "  occasional  severe  "  pains, 
numbering  20.  Setting  aside  this  group,  again,  there  were  left  216  cases, 
or  2 1. 1  per  cent  of  the  entire  series,  who  may  be  said  to  have  experienced 
habitual  menstrual  pain. 

(c)  Those  with  severe  pains,  requiring  rest  in  bed  for  one  or  more  days 
each  month,  numbering  152,  or  5.3  per  cent  of  the  total  number. 

This  study  would  seem  to  demonstrate  the  fallacy  of  the  view  held  by 
many  that  more  or  less  pain  is  the  rule  with  menstruation. 

Site  of  Pain  or  Discomfort. —  Chisholm  gives  the  principal  locations 
of  the  menstrual  disturbance,  especially  pain,  in  girls  and  adults  respectively, 
in  the  following  table : 


Location  of  Menstrual  Pain 


Pain  in  abdomen 

Indefinite  discomfort,  mostly  referred  to  abdomen.. 

Pain  in  back  alone 

Pain  in  back  and  front .  . 

Pain  in  legs 

Instability  or  mental  disturbance 

Headache  or  general  physical  disturbance 


girls 

ADULTS 

fM^y^^ 

32% 

6.z% 

6.4% 

6.3% 

9.6% 

5-5% 

19% 

15% 

2.8% 

19% 

CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  83 

Other  Subjective  Symptoms  of  Menstruation. —  Other  symptoms 
frequently  noted  in  the  menstruating  woman  are  headache,  a  general  sense 
of  lassitude,  depression  and  nervousness,  irritability  of  the  bladder,  impair- 
ment of  digestion,  sometimes  constipation,  and  occasionally  nausea  or  even 
vomiting.  Not  a  few  women  suffer  with  pain  about  the  breasts,  usually 
slight,  but  occasionally  quite  sharp  and  lancinating. 

In  some  women  the  thyroid  becomes  swollen  during  menstruation,  giving 
rise  to  increased  fullness  of  the  neck.  Digestion  is  sometimes  impaired, 
and  often  the  breath  is  rather  heavy.  Krieger  found  diarrhea  in  almost 
one  half  the  cases  he  studied,  although  toward  the  end  of  the  period,  consti- 
pation was  quite  frequent.     Salivation  has  been  noted,  but  is  not  common. 

"Many  women  exhibit  overactivity  of  the  skin,  characterized  by  increased 
sweating.  The  sebaceous  glands  of  the  vulva  and  perineum  also  become 
overactive.  A  similar  activity  of  the  sebaceous  glands  of  the  face  some- 
times give  rise  to  acne-like  pustules.  The  occurrence  of  various  other  men- 
strual eruptions  will  be  discussed  in  Chapter  XXV.  The  face  is  apt  to  be 
rather  pale,  and  in, some  women  "  dark  rings"  form  under  the  eyes.  The 
bladder  symptoms  consist  especially  in  increased  frequency  of  urination. 
These  would  seem  to  be  explainable  by  the  pelvic  hyperemia  associated  with 
menstruation,  in  which  the  bladder  also  shares  to  a  certain  extent. 

Statistics  of  Character  and  Severity  of  Subjective  Symptoms. —  Geb- 
hard,  in  Veit's  Handhuch  der  Gyndkologie,  states  that  a  minority  of  women 
suffer  no  discomfort  during  menstruation,  the  majority  complaining  of  such 
symptoms  as  headache,  a  feeling  of  pressure  in  the  abdomen,  lassitude,  loss 
of  appetite,  mental  irritability  and  a  tendency  to  weep.  Somewhat  similar 
generalizations  are  made  by  Martin,  Fehling,  and  Pozzi. 

Jane  Ketcham,  in  191 1,  made  a  study  of  this  subject  in  200  women,  vary- 
ing in  age  from  10  to  45  years,  and  embracing  school  girls,  college  girls, 
factory  girls,  clerks,  stenographers,  and  school  teachers.  Like  Chisholm's 
study,  this  investigation  was  based  on  the  responses  to  a  questionnaire. 
While  few  figures  are  given,  the  statement  is  made  that  the  large  majority 
of  women  suffer  little  or  no  pain  at  the  onset  of  menstruation,  i.  e,  during 
the  time  the  function  is  becoming  established.  In  5  per  cent  of  Ketcham's 
cases  the  flow  was  preceded  by  nausea  and  vomiting,  varying  in  severity 
and  lasting  from  one  to  several  hours. 

In  factory  girls,  aged  16  to  25  years,  there  were  many  cases  of  acute  pain 
for  a  few  hours,  although  the  great  majority  complained  only  of  general 
malaise,  often  with  headache.  In  the  older  women,  such  as  the  school 
teachers,  aged  25  to  40  years,  in  the  earlier  years  of  their  menstrual  history 
they  had  either  had  no  pain  or  else  it  was  comparatively  slight.  As  the 
years  had  gone  on,  however,  the  menses  had  become  increasingly  painful, 
often  causing  incapacitation  from  work.  The  question,  "  Do  you  follow 
your  regular  work  at  this  time?"  brought  a  rather  surprising  response. 
Clerks,  stenographers  and  school  teachers  often  found  it  necessary  to  rest 


84 


MENSTRUATION  AND  ITS  DISORDERS 


occasionally,  while  mothers  of  large  families,  often  engaged  in  quite  labori- 
ous work,  rarely  found  it  necessary  to  depart  from  their  usual  routine  work. 
Perhaps  the  most  exhaustive  study  of  this  subject,  however,  is  that  of 
Marie  Tobler,  based  on  a  careful  analysis  of  the  menstrual  histories  of  1020 
women.  The  following  table  presents  in  a  graphic  way  the  results  of  her 
study  —  the  character  and  intensity  of  subjective  symptoms,  as  well  as  the 
time  of  appearance  of  the  symptoms : 


CHARACTER   OF   SYMPTOMS 


1.  No  discomfort 

2.  Slight  local  discomfort.  . . . 

3.  General  symptoms  without 

local  discomfort 

4.  General    and   local    symp- 

toms both 

5.  Psychic  disturbance  with- 

out local  symptoms.  . .  . 

6.  Psychic   and    local    symp- 

toms both 

7.  General  and  psychic  symp- 

toms without  local  sign . 

8.  General,  psychic  and  local 

symptoms 

9.  Actual    increase    of     well 

being 

10.  Increase  of  well  being,  with 
some  discomfort 

Total 


No. 

of 

cases 


161 

45 

70 

149 

80 

57 
117 
270 

34 
37 


1020 


Per 
cent 


15 
4 

6 

14 

7 

5 

II 

26 

3 
3 


TIME  OF  APPEARANCE  OF 
SYMPTOMS 


Pre-  and 

Pre- 

Intra- 

intra- 

men- 

men- 

men- 

strual 

strual 

strual 

Per  cent 

Per  cent 

Per  cent 

34 

30 

36 

24 

39 

Z7 

57 

26 

17 

44 

32 

24 

27 

13 

60 

14 

16 

70 

12 

67 

21 

38 

57 

5 

250 

280 

270 

The  "  Libido  Sexualis  "  and  Menstruation. —  The  lihido  sexualis  is, 
in  the  opinion  of  most  authors,  somewhat  diminished  during  menstruation. 
Havelock  Ellis,  on  the  other  hand,  is  convinced  from  his  extensive  inquiries 
that,  while  the  aversion  to  coitus  at  the  menstrual  period  is  real,  it  is  not 
due  to  any  lessening  of  sexual  desire  at  that  time.  Gehrung  also  states 
that  in  healthy  young  girls  amorous  sensations  are  normal  during  men- 
struation. 

However  this  may  be,  there  seems  to  be  general  agreement  among  author- 
ities that  sexual  feeling  is  heightened  just  before  and  just  after  menstrua- 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  85 

tion.  ( Krafft-Ebing,  Adler,  Kossman,  Guyot,  etc.)  The  inquiries  of 
Campbell  among  a  large  number  of  cases,  indicate  that  in  two  thirds  of  the 
entire  number  in  which  a  connection  had  been  observed  between  menstrua- 
tion and  the  sexual  desire,  the  latter  was  increased  either  just  before,  during, 
or  just  after  the  flow. 

It  must  be  said,  however,  that  the  existence  of  a  relation  between  men- 
struation and  sexual  desire  has  been  denied  by  some  authors,  especially  those 
who  are  opposed  to  the  view  that  there  is  any  analogy  between  menstruation 
in  woman  and  estrus  in  the  lower  animals.  The  latter  period  is  the  period 
of  sexual  desire  among  animals.  It  has,  however,  already  been  emphasized 
that  it  is  the  premenstrual  rather  than  the  menstrual  epoch  in  woman  which 
corresponds  to  the  period  of  heat  in  the  lower  animals  (Chapter  II). 

Elizabeth  Blackwell,  in  her  work  on  "  The  Human  Element  in  Sex," 
states  that  the  menstrual  discharge  in  itself  gives  complete  relief  for  the 
sexual  feelings  in  women,  thus  comparing  them  to  the  nocturnal  emissions 
of  men.  This  opinion  of  Dr.  Blackwell,  as  Ellis  points  out,  is  a  survival  of 
a  belief  which  was  prevalent  a  century  or  more  ago,  when  various  writers 
regarded  menstruation  as  a  "  device  of  Providence  for  safeguarding  the 
virginity  of  women." 

The  "  Menstrual  Wave  "  Theory. —  The  menstrual  symptoms  are  by 
some  looked  upon  as  due  to  the  presence  in  the  circulating  blood  of  certain 
products  which  reach  their  maximum  just  before  menstruation  begins 
(Tobler,  Schickele).  This  concept  is  at  the  bottom  of  the  so-called  "  men- 
strual wave  "  theory.  Although  the  "  menstrual  wave  "  is  often  alluded  to 
as  "  Stephenson's  wave,"  the  theory  had  been  enunciated  by  Raciborski  in 
1868,  some  fourteen  years  before  the  appearance  of  Stephenson's  paper. 

In  1878  was  published  the  much  referred  to  work  of  Mary  Jacobi  on 
"  The  Question  of  Rest  for  Women  During  Menstruation."  According 
to  her  observations  the  body  temperature  of  the  woman  rises  from  0.05  °C 
to  0.44°  C  in  the  week  before  menstruation,  and  falls  during  the  progress 
of  the  menstrual  bleeding  from  o,03°C  to  o.25°C,  seldom  getting  quite  down 
to  normal  during  the  period. 

In  the  same  year  with  the  publication  of  Jacobl's  paper  came  that  of 
Goodman  on  "  The  Cyclical  Theory  of  Menstruation."  According  to  Good- 
man, the  vital  activities  of  women  progress  in  wave-like  fashion,  the  length 
of  the  waves  corresponding  to  that  of  the  intermenstrual  intervals.  Each 
of  these  waves  exhibits  an  ebb  and  a  flow,  in  which  there  is  a  decrease  and 
then  an  increase  in  such  vital  factors  as  the  body  temperature,  the  blood 
pressure,  the  pulse  beat,  etc. 

Stephenson's  paper,  "  On  the  Menstrual  Wave,"  was  published  four 
years  later,  in  1882,  According  to  him  the  maximum  of  the  temperature 
increase  occurs,  not  at  the  beginning  of  menstruation,  but  about  five  days 
before.  Otherwise  his  assumption  of  the  "  menstrual  wave  "  differs  in  no 
material  way  from  that  of  Goodman. 

The  publication  of  a  detailed  study  of  57  women  during  68  menstrual 


86  MENSTRUATION  AND  ITS  DISORDERS 

periods  by  von  Ott  in  1889  added  a  strong  confirmation  to  the  theory  that 
the  pulse  rate,  blood  pressure,  body  temperature,  and  muscle  power,  all 
increase  before  the  beginning  of  menstruation,  and  then  diminish  with  the 
onset  of  the  menstrual  bleeding.  Other  writers  who  have  at  various  times 
supported  this  general  belief  are  Chazan  (1888  and  1899),  Schiile  (1896), 
Gebhard  (1898),  Schroder  (1898),  Martin  (1899),  Fehling  (1900),  Mer- 
letti  (1900),  Brennecke  (1902),  Bumm  (1902),  Marie  Tobler  (1905), 
Jung  (1907),  Siredey  and  Francillon  (1905),  and  others. 

On  the  other  hand,  Halliburton  (1893),  ver  Eerecke  (1897)  ^"^  Meyer 
(1890)  have  expressed  disagreement,  largely  on  the  ground  that  the  obser- 
vations were  not  carried  out  exclusively  on  healthy  women.  Bayer  (1906) 
also  expresses  the  opinion  that  the  term  "  menstrual  wave  "  has  not,  to  say 
the  least,  been  conducive  to  progress  in  the  study  of  the  phenomenon  of 
menstruation.  He  emphasizes  the  advantage  of  the  term  "  menstrual 
period." 

The  best  recent  study  of  this  problem  has  been  that  of  Viville  (1912). 
This  investigator  seems  to  have  avoided  the  objections  which  had  been 
made  to  the  work  of  many  of  the  previous  writers  on  the  subject,  because 
he  exercised  the  greatest  care  in  the  selection  of  his  46  patients,  and  regu- 
lated the  conditions  surrounding  the  study.  His  findings,  in  brief,  are  as 
follows :  ( I )  The  blood  pressure  is  increased  during  menstruation  in 
almost  the  same  proportion  of  cases  as  it  is  decreased,  and  is  increased  or 
decreased  in  about  the  same  proportion  of  cases  during  or  after  the  periods. 
(2)  The  same  statement  may  be  made  of  the  pulse  rate  and  the  body  tem- 
perature. (3)  The  muscle  power  in  the  right  or  left  hand  (estimated  by 
the  dynamometer)  is  increased  or  decreased  in  about  an  equal  number  of 
cases. 

In  other  words,  he  finds  no  evidence  to  support  the  view  that  there  are 
wave-like  fluctuations  in  the  activity  of  these  various  body  functions,  cor- 
responding to  the  menstrual  cycles. 

A  word  of  detail  may  now  be  added  with  regard  to  the  effect  of  men- 
struation upon  the  various  functions  which  have  been  already  alluded  to  in 
the  discussion  of  the  "  wave  theory,"  i.  e.,  the  body  temperature,  the  blood 
pressure,  the  pulse  rate,  and  the  muscle  power. 

Effect  of  Menstruation  on  Body  Temperature. —  The  first  observa- 
tion to  which  I  can  find  reference  on  this  subject  is  by  Fricke  (1838),  who 
studied  the  temperature  before  and  during  the  periods  in  24  young  women, 
finding  such  slight  variations  that  he  concluded  that  menstruation  exerts 
little  or  no  effect  on  the  body  temperature.  The  work  of  Jacobi  and 
Stephenson  has  already  been  alluded  to.  Kersch  (1882)  concluded  that 
menstruation  evokes  a  rise  of  temperature  varying  from  a  maximum  of 
i.o°C  down  to  o.7°C. 

Similar  results  were  reported  by  Henning  (1882).  Reinl  (1884)  and 
Giles  (1896)  both  found  that  the  temperature  is  at  its  low  point  at  about 
the  middle  of  the  intermenstrual  period,  rising  then  gradually  to  its  max- 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  87 

imum  a  day  or  two  before  the  beginning  of  the  menstrual  bleeding,  after 
which  it  drops  quite  suddenly.  Somewhat  similar  results  were  arrived  at 
by  Murchy  (1901)  and  Van  der  Velde  (1904).  Reference  has  already 
been  made  to  the  work  of  Marie  Tobler,  who  like  other  observers,  described 
a  dropping  of  the  temperature  at  the  menstrual  period.  King's  recent  study 
(1914)  tends  also  to  support  this  view. 

The  importance  of  a  premenstrual  rise  of  temperature  as  a  diagnostic 
sign  of  early  tuberculosis  was  first  emphasized  by  von  Riebold  (1896), 
Turban  (1899),  and  later  by  Sabourin  (1903),  Leube  (1904),  Saugman 
(1904),  Kraus-  (1905)  and  Oster  (1910).      (See  Chapter  XXV.) 

The  study  of  Viville,  finally,  showed  that  of  47  patients  examined,  the 
temperature  was  unchanged  in  44,  that  it  was  slightly  raised  during  men- 
struation in  I,  and  lowered  in  2,  v\?hile  after  menstruation  it  was  raised  in 
none  and  diminished  in  none.  The  indication  is,  therefore,  that  there  is  no 
characteristic  effect  exerted  by  menstruation  on  the  body  temperature. 

Effect  of  Menstruation  on  Blood  Pressure. —  As  far  back  as  1879 
Rohrig,  on  the  assumption  that  menstruation  is  due  to  a  stimulation  of  the 
ovaries,  found  that  by  electric  stimulation  of  these  organs  he  could  produce 
an  increase  in  the  blood  pressure.  Von  Ott  (1889)  stated  that  in  13  of  the 
14  cases  which  he  studied,  the  beginning  of  the  menstrual  flow  was  accom- 
panied by  a  lowering  of  the  blood  pressure.  Giles  (1896)  found  it  highest 
at  the  beginning  or  on  the  first  day  or  two  of  the  flow,  and  lowest  at  the 
end  of  the  menstrual  period.  Wiessner  (1899)  states  that  during  the 
catamenia  the  blood  pressure  drops  about  20  mm.,  reaching  its  normal  again 
3  or  4  days  after  the  cessation  of  the  period. 

Viville  (1912),  in  his  recent  work  on  the  subject,  finds,  in  the  study  of 
47  patients,  that  34  showed  no  change,  6  showed  an  increase  and  4  a 
decrease  in  blood  pressure  during  menstruation,  while  after  menstruation 
none  exhibited  an  increase  and  3  a  decrease.  It  would  be  difificult,  from 
these  figures,  to  ascribe  to  menstruation  any  important  influence  on  blood 
pressure.     The  same  conclusion  is  reached  by  King  (1914). 

Effect  of  Menstruation  on  Pulse  Rate. —  As  early  as  1779,  Borden 
spoke  of  the  pulse  during  menstruation  as  "  tense,  irregular  and  dicrotic." 
This  was  reaffirmed  later  by  Gonot  (1810)  and  Desforges  (1813).  The 
first  accurate  observations  on  the  variations  in  the  pulse  rate  under  men- 
strual influence  were  those  of  Brierre  de  Boismont  (1842).  By  ausculta- 
tory examination  of  104  women,  he  found  in  62  a  slight  acceleration  of  the 
pulse  during  the  menstrual  period.  In  14  women  the  increase  was  striking. 
The  remaining  28  women  exhibited  either  no  influence  on  the  heart  rate  or 
a  slight  slowing. 

Passing  over  the  work  of  Jacobi,  Goodman,  and  Stephenson,  we  may 
allude  to  the  contributions  of  Zweifel  (1899)  and  Zuntz  (1906),  both  of 
whom  stated  that  the  pulse  is  slowed  during  the  menstrual  period,  after 
having  reached  its  high  point  in  the  premenstrual  epoch.  Viville  (1912), 
in  his  47  cases,  found  that  the  pulse  was  virtually  unchanged  in  34,  increased 


88  MENSTRUATION  AND  ITS  DISORDERS 

in  7  and  decreased  in  4  during  menstruation,  and  increased  in  none  and 
decreased  in  2  after  menstruation.  He  finds  no  evidence  to  point  to  an 
influence  on  the  part  of  the  menstrual  process. 

Effect  of  Menstruation  on  the  Muscle  Power. —  The  general 
weakness  and  lassitude  so  often  noted  during  menstruation  has  led  to  efforts 
to  determine  accurately  any  changes  in  muscular  capacity  at  that  time.  As 
in  the  case  of  the  variations  in  pulse,  blood  pressure  and  temperature,  the 
work  of  Viville  showed  that  there  is  no  characteristic  effect  produced  by 
menstruation  on  muscle  power,  as  tested  by  means  of  the  Potain  dyna- 
mometer. The  study  of  8  cases  by  Schmotkin  confirms  Viville's  results. 
The  latter  in  a  series  of  41  cases,  tested  by  the  dynamometer,  found  no 
deviation  from  the  normal  in  37. 

Effect  of  Menstruation  on  Knee  Jerk. —  An  interesting  study  by 
King  of  the  knee  jerk  in  women  at  various  phases  of  the  monthly  cycle 
showed  that  "  a  period  of  hyperexcitability  immediately  precedes  or  accom- 
panies the  onset  of  the  menstrual  period ;  that  this  is  followed  by  a  decline 
in  excitability  which  continues  for  a  few  days  after  the  menses  have  ceased ; 
and  that  there  is  then  a  tendency  for  it  to  rise  to  a  slightly  higher  level  than 
the  preceding  during  the  intermenstrual  interval." 

Periodicity  of  the  Menstrual  Flow. —  The  remarkable  regularity  with 
which  menstruation  recurs  throughout  the  sexual  life  of  the  woman  is  per- 
haps the  most  difficult  of  explanation  of  all  the  characteristics  of  the  process. 
As  is  well  known,  there  is  in  many  girls  a  marked  tendency  toward  irregu- 
larity for  some  time  after  the  inauguration  of  the  function.  The  statistics 
of  Emmett,  based  upon  2447  cases,  showed  that  in  72.33  per  cent,  men- 
struation was  regular  from  the  beginning.  In  18.92  per  cent  it  became 
regular  after  a  certain  time,  and  in  8.74  per  cent  it  was  never  regular. 
According  to  Emmett,  the  average  time  required  for  the  function  to  become 
regular,  when  it  commenced  irregularly,  was  eighteen  months  after  the  first 
appearance.  The  proportion  of  sterile  married  women  who  were  never 
resrular  was  shown  to  be  somewhat  smaller  than  that  of  unmarried  women. 

Osterloh  found  that  menstruation  was  regular  in  68  per  cent  of  a  large 
number  of  healthy  women  he  studied,  always  irregular  in  21  per  cent,  and 
variable  in  the  remaining  1 1  per  cent. 

The  most  elaborate  investigation  on  this  subject  is  that  of  Sanes,  based 
on  4500  menstrual  histories.  He  finds  that  75  per  cent  of  this  series  of 
women  menstruated  regularly,  and  25  per  cent  irregularly. 

Even  when  a  patient  believes  and  states  that  her  menstruation  occurs 
quite  regularly  every  twenty-eight  days,  it  is  surprising  how  frequently  a 
careful  record  of  the  menstrual  dates  will  disclose  slight  deviations  from 
this  rhythm.  This  fact  was  brought  out  in  an  investigation  by  Foster  in 
1889.  Of  fifty-six  women  whom  he  studied,  in  only  one  instance  did  he 
note  perfect  periodicity,  the  interval  in  this  case  being  twenty-six  days. 
The  number  of  menstrual  periods  observed  in  each  woman  varied  from  five 
to  eighteen.     There  was  a  difference  of   i   day  in   i   case,  2  days  in  4 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION 


89 


cases,  3  days  in  3  cases,  4  days  in  8  cases,  5  days  in  6  cases,  6  days  in  4 
cases,  9  days  in  4  cases,  10  days  in  i  case,  11  days  in  6  cases,  12  days  in 
2  cases,  13  days  in  2  cases,  16  days  in  2  cases,  17  days  in  i  case,  and  18 
days  in  i  case.  Out  of  a  total  of  380  menstrual  periods  observed,  45  had 
taken  place  after  an  interval  of  28  days,  225  after  shorter  intervals  (the 
shortest  being  16  days),  and  no  after  longer  intervals  (the  longest  being 
46  days).  And  yet  all  the  women  in  the  series  were  healthy  and  had  stated 
that  they  were  regular  in  menstruation. 

It  is  not  uncommon  to  hear  women  say  that  they  menstruate  on  the  same 
date  each  moilth.  Such  a  statement  should  make  one  skeptical  as  to  the 
woman's  accuracy,  if  we  bear  in  mind  the  difference  in  the  lengths  of  the 
solar  months.  This  is  certainly  a  more  logical  assumption  than  to  explain 
the  occurrence  on  the  ground  of  psychical  autosuggestion  on  the  part  of 
the  woman,  as  has  been  suggested. 

The  Interval  Between  Menstrual  Periods. —  The  duration  of  the 
entire  menstrual  cycle,  in  by  far  the  largest  number  of  women,  is  twenty- 
eight  days.  A  considerable  number,  however,  menstruate  regularly  at 
intervals  of  twenty-one  days,  and  a  few  every  fourteen  days.  It  is  thus 
seen  that  the  interval  of  days  between  the  periods  is  most  frequently  some 
multiple  of  seven,  a  fact  to  which  some  significance  was  attached  by  the 
ancients.  Since  it  is  true  that  menstruation  usually  begins  at  the  second 
septenary  and  ceases  at  about  the  seventh,  it  is  not  surprising  that  they 
ascribed  to  the  figure  seven  a  rather  mystic  role  in  connection  with 
menstruation. 

The  predominance  of  the  twenty-eight  day  type  of  menstruation  over 
other  types  is  evident  from  a  study  of  the  available  statistics.  In  1000 
cases,  studied  by  Kelly,  this  type  made  up  fully  94.2  per  cent  of  the  cases. 
He  gives  the  following  table  showing  the  interval  between  the  menstrual 
periods  in  these  1000  cases: 

Table  Showing  Interval  Between  Menstrual  Periods  in  iooo  Cases 


The  statistics  of  Krieger  show  that  menstruation  was  of  the  28  day  type 
in  70  per  cent  of  his  cases,  the  next  most  frequent  being  the  30  day  type 
(13.7  per  cent). 

Webster,  as  well  as  Hart  and  Barbour,  give  71  per  cent  as  the  proportion 
of  cases  with  an  interval  of  28  days,  and  14  per  cent  with  an  interval  of  30 
days. 


90 


MENSTRUATION  AND  ITS  DISORDERS 


The  exhaustive  study  of  4500  menstrual  histories  by  Sanes,  already  re- 
ferred to,  showed  that  the  most  common  regular  type  met  with  was  that 
of  twenty-eight  days,  which  constituted  'J2  per  cent.  The  30  day  type 
followed  next  in  frequency,  but  with  only  3.8  per  cent,  and  the  21  day  type 
with  3.3  per  cent,  etc.  The  most  common  irregular  types  were  from  three 
to  four  weeks,  then  from  four  to  five  weeks,  two  to  three  weeks,  five  to  six 
weeks,  etc. 

Duration  of  the  Menstrual  Periods. —  Much  variation  is  seen  in  the 
duration  of  the  flow  in  different  women.  The  important  fact,  from  a  prac- 
tical view^point,  is  that  within  certain  rather  narrow  limits  every  woman  has 
her  own  standard,  by  which  she  may  judge  of  the  advent  of  abnormality. 
The  average  duration  given  by  Emmett,  from  the  study  of  a  large  number 
of  cases,  is  4.82  days.  Among  women  who  have  children,  the  duration  was 
4.91  days,  Vk^hile  among  sterile  women  it  was  4.74  days.  Among  the  un- 
married the  flow  was  of  a  shorter  duration  than  for  any  other  class  of 
women. 

The  average  duration  of  menstruation,  as  given  by  Hirst,  is  3  to  7  days ; 
by  Garrigues,  4  days ;  Montgomery,  2  to  8  days ;  Penrose,  2  to  7  days ; 
Gilliam,  4  to  5  days ;  Keating  and  Coe,  4  to  5  days ;  Ashton,  3  to  6  days ; 
Hart  and  Barbour,  2  to  8  days.  The  figures  given  by  most  of  those  au- 
thors, however,  are  not  based  on  personal  statistical  studies.  Kelly,  on 
the  other  hand,  has  made  an  investigation  of  1000  personal  cases  from 
this  standpoint.  The  duration  of  menstruation  in  these  cases  is  given  in 
tabular  form,  as  follows : 

Table  Showing  Duration  of  Menstruation  in  iooo  Cases 


Kelly  emphasizes  the  fact  that  in  those  cases  in  which  the  duration  of 
menstruation  was  over  six  days,  the  amount  was  described  as  excessive. 
In  200  cases  in  which  menstruation  lasted  more  than  six  days  it  was  de- 
scribed as  free  in  52,  and  as  excessive  in  68.  In  other  words,  in  120,  or 
three  fifths  of  the  entire  number,  menstruation  was  in  excess  of  the  nor- 
mal. He  concludes  that  "  a  duration  of  more  than  six  days  is  so  frequently 
pathologic  that  it  should  never  be  regarded  as  normal,  unless  it  is  clear 
from  other  data  that  the  patient's  health  is  fully  up  to  par."  From  a 
physiologic  point  of  view,  this  association  of  abnormality  in  duration  with 
abnormality  in  amount  suggests  that  the  same  factor  is  capable  of  causing 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  91 

both.      Sanes'  recent  study,  finally,  gives  the  most  common  duration  of  the 
menstrual  flow  as  3  days,  then  4  to  5  days,  5  days,  7  days,  and  4  days. 

AMOUNT  OF  BLOOD  LOST  AT  MENSTRUATION 

Individual  Differences. —  As  regards  the  amount  of  blood  lost  at  each 
menstrual  period,  even  greater  individual  differences  are  seen  than  in  the 
duration  of  the  flow.  Every  woman  is  a  law  unto  herself,  so  that  the 
menstrual  bleeding  may  be  considered  abnormally  free  or  abnormally  scanty 
onh'-  when  it  is  definitely  greater  or  less  in  amount,  as  the  case  may  be, 
than  is  customary  for  the  woman. 

Methods  of  Estimating  Amount. —  The  indefiniteness  of  our  knowl- 
edge concerning  the  exact,  or  perhaps  better,  the  average  amount  of  blood 
lost  with  the  menses  is  due  largely  to  the  obvious  difficulties  of  measuring 
or  even  estimating  the  amounts.  The  common  method  of  estimating  the 
amount  of  blood  lost  by  the  number  of  napkins  soiled  is  crude  and  inac- 
curate, although  it  may  serve  as  a  guide  to  any  very  great  increase  or  de- 
crease in  the  intensity  of  the  flow.  A  more  scientific  method  is  that  of  esti- 
mating the  amount  of  blood  lost  by  determining  first  the  exact  amount  of 
hemoglobin  which  may  be  recovered  from  the  soiled  protectives  worn  during 
the  period. 

Amount  of  Menstrual  Discharge. —  The  widest  divergence  of  opinion 
exists  with  regard  to  the  amount  of  blood  lost  at  the  menstrual  periods. 
Hippocrates  stated  that  the  amount  lost  by  Greek  women  was  20  ounces. 
Galen  gave  the  quantity  as  18  ounces.  For  German  women  von  Haller 
placed  the  amount  at  6,  8,  or  12  ounces,  while  for  English  women  it  was 
put  by  Smellie  and  Dobson  at  4  ounces,  by  Pasta  at  5  ounces,  and  by 
Freind  at  10  ounces. 

Gorter,  for  the  women  of  Holland,  gives  the  amount  as  not  over  6  ounces, 
and  Fitzgerald,  for  Spanish  women,  as  14  to  15  ounces.  Astruc  states 
that  French  women  lose  8  to  10  ounces  of  blood,  while  Baudelocque,  for 
the  same  nationality,  gives  3  or  4  ounces.  Magendie  merely  states  that 
the  amount  lost  Is  often  very  great  and  may  be  as  much  as  several  pounds. 
Linnaeus,  in  his  "  Flora  Laponica  ",  states  that  the  women  of  the  frozen 
north,  such  as  the  Samoides,  lose  only  a  very  small  amount  of  blood,  and 
that  only  In  the  summer  months,  while  the  Greenlanders  have  scarcely 
any  discharge.  These  statements  agree  with  those  of  various  Arctic  ex- 
plorers. Hoppe-Seiler  believes  that  the  amount  of  menstrual  blood  lost  is 
rarely  over  about  37  cubic  centimeters. 

While  there  Is  the  greatest  divergence  In  the  estimates  of  various  authors, 
it  Is  probably  not  far  from  correct  to  say  that  In  the  temperate  climate  the 
average  amount  of  blood  lost  at  the  menstrual  periods  Is  from  2  to  6  or  8 
ounces,  although,  as  has  already  been  stated,  the  Individual  differences  are 
great.  The  greater  portion  of  the  blood  Is  lost  during  the  first  half  of  the 
period,     With  most  women,  it  Is  perhaps  the  second  day  on  which  more  is 


92  MENSTRUATION  AND  ITS  DISORDERS 

lost  than  on  any  other,  while  during  the  first  day,  before  the  flow  is  well 
established,  the  amount  lost  is  usually  not  so  great. 

Influence  of  Menstruation  on  Blood  Picture. —  While  many  investi- 
gators have  concerned  themselves  with  the  study  of  the  alterations  produced 
in  the  blood  picture  by  menstruation,  the  conclusions  arrived  at  are  not  as 
yet  as  clearly  defined  as  might  be  wished.  The  best  recent  study  of  the 
subject  is  that  of  Gumprich,  who  has  also  given  us  a  thorough  resume  of 
the  literature. 

Erythrocytes. —  The  first  contributions  were  those  of  Hayem  and 
Reinl,  who  observed  an  intramcnstrual  diminution  and  a  postmenstrual 
increase  in  the  proportion  of  erythrocytes.  Schwinge,  Sfameni,  Merletti, 
and  Ricca-Barberis  arrived  at  somewhat  the  same  conclusions.  Blumen- 
thal  placed  the  decrease  in  red  corpuscles  during  menstruation  as  high  as 
one  million  per  cubic  millimeter.  A  similar  decrease  was  recorded  by 
Carnot  and  Deflandre,  who  stated  that  it  is  not  until  the  tenth  or  twelfth 
day  after  the  beginning  of  menstruation  that  the  blood  again  shows  the 
normal  number  of  red  corpuscles.  Krutschenoff  also  observed  counts  as 
low  as  three  million  red  corpuscles  during  menstruation. 

The  objection  to  all  these  studies,  as  Gumprich  has  pointed  out,  is  the 
fact  that  the  number  of  cases  on  which  they  are  based  is  much  too  small  to 
draw  general  conclusions,  especially  since,  as  a  rule,  the  women  were  studied 
during  one  period  only. 

The  study  of  seventeen  women  through  three  menstrual  periods,  as  re- 
ported by  Anna  Polzl,  would  seem  to  promise  more  reliable  results.  This 
author  found  in  eight  of  her  cases  that  a  few  days  before  the  onset  of  men- 
struation there  is  a  very  definite  increase  of  erythrocytes,  as  much  as  one  or 
one  and  a  half  millions.  This  is  followed  by  a  fall  up  to  the  two  days 
before  the  onset  of  the  bleeding,  while  a  second  rise  occurs  after  menstru- 
ation. In  the  remaining  nine  cases,  however,  her  results  are  not  nearly  so 
definite,  and,  in  some  respects  they  are  rather  contradictory. 

Gumprich  finds  that  the  variations  of  the  erythrocytes  are  usually  only 
a  few  hundred  thousand,  rarely  over  a  million,  and  never  so  high  as  stated 
by  Carnot  and  Deflandre,  Krutschenoff  and  Polzl.  These  fluctuations, 
according  to  Gumprich,  can  scarcely  be  looked  upon  as  directly  related 
with  menstruation,  inasmuch  as  the  same  individual  at  times  shows  an 
increase,  at  times  a  decrease  during  menstruation. 

Hemoglobin. — ■  Similar  discrepancies  are  seen  in  the  opinions  of  dif- 
ferent investigators  with  regard  to  the  menstrual  variations  in  the  hem- 
oglobin content  of  the  blood.  Hayem,  Reinl,  Merletti  and  Ricca-Bar- 
beris describe  a  premenstrual  decrease  and  an  intramcnstrual  increase  in 
the  hemoglobin,  while  Sfameni,  Pozzi,  and  Blumenthal  speak  of  a  decrease 
during  menstruation.  According  to  Polzl  there  occur  only  very  slight 
fluctuations  in  the  proportion  of  hemoglobin.  This  is  also  the  conclusion 
of  Gumprich,  who  states  that  the  slight  variations  noted  can  scarcely  be 
attributed  to  any  influence  on  the  part  of  menstruation. 


CLINICAL  CHAIL\CTERISTICS  OF  NORMAL  MENSTRUATION  93 

Leukocytes. —  The  proportion  of  leukocytes  in  normal  blood  is  subject  to 
the  influence  of  many  factors.  As  is  well  known,  a  physiological  leukocy- 
tosis is  caused  by  severe  exercise,  by  a  hearty  meal,  by  cold  baths,  etc.  It 
is  scarcely  necessary,  therefore,  to  emphasize  the  care  with  which  deduc- 
tions must  be  drawn  with  regard  to  the  influence  of  menstruation  upon  the 
proportion  of  white  blood  corpuscles.  Hayem  found  an  increase  of  from 
one  to  two  thousand  during  menstruation.  Reinert,  Moleschott,  Schwinge, 
Birnbaum,  Horvath,  and  others  have  also  described  an  increase  in  the  num- 
ber of  leukocytes  during  menstruation.  Blumenthal,  on  the  other  hand, 
observed  a  decrease  in  four  normal  cases.  Dirks,  in  the  study  of  sixteen 
cases  during  menstruation,  found  that  all  showed  leukocyte  counts  above 
normal. 

Gumprich,  while  agreeing  that  in  general  a  moderate  menstrual  leukocy- 
tosis does  occur,  feels  that  this  statement  should  be  qualified.  As  a  rule 
the  leukocytosis  is  highest  on  the  first  day  of  menstruation,  then  drops 
almost  as  sharply  as  it  had  risen.  In  addition  to  the  menstrual  rise,  how- 
ever, he  finds  that  a  study  of  the  blood  in  the  intermenstrual  periods  often 
discloses  similar  periods  of  increase,  almost  as  marked  as  at  menstruation, 
so  that  we  must  qualify  our  views  of  the  significance  of  the  usual  men- 
strual leukocytosis. 

With  regard  to  the  differential  study  of  the  leukocytes,  as  influenced  by 
menstruation,  there  is  considerable  difference  of  opinion  amiong  investi- 
gators. No  definite  conclusions  were  arrived  at  by  Birnbaum,  Neusser, 
Carstanyen  and  Horvath.  Ricca-Barberis  described  an  increase  in  the 
number  of  lymphocytes  and  an  irregular  fluctuation  in  the  number  of 
eosinophils.  Blumenthal  found  in  four  normal  cases  that  toward  the 
end  of  the  menstrual  bleeding  there  was  a  decrease  in  the  neutrophil 
polynuclears  and  a  corresponding  increase  in  the  mononuclears.  The 
eosinophils  also  increase  regularly.  Dirks  found  in  nine  of  his  sixteen 
cases  an  increase  of  lymphocytes  at  menstruation,  in  two  a  decrease,  and 
in  the  remaining  five  an  increase  and  a  decrease  at  different  menstrual 
periods.  With  regard  to  the  eosinophils,  his  results  also  are  indecisive, 
since  in  six  cases  their  number  was  increased,  and  in  the  remainder 
unchanged.  In  menorrhagia,  incidentally,  he  found  usually  a  relative 
leukocytosis  with  a  corresponding  decrease  in  the  lymphocytes,  and  often 
with  eosinophilia.  In  amenorrhea,  on  the  other  hand,  he  found  a  relative 
lymphocytosis  and  a  low  eosinophil  count.  Herman  found  that  the 
lymphocytes  increase  significantly  during  menstruation. 

Gumprich  asserts  that  the  lymphocyte  curve  shows  such  marked  indi- 
vidual fluctuations  in  the  direction  of  either  increase  or  decrease,  that  he 
does  not  hold  menstruation  responsible  for  any  apparent  variation  in  the 
number  of  these  elements.  The  same  general  rule  also,  according  to  Gump- 
rich, applies  to  the  eosinophils. 

To  sum  up,  therefore,  we  must  conclude  that  it  has  not  as  yet  been  dem- 


94 


MENSTRUATION  AND  ITS  DISORDERS 


onstrated  that  menstruation  gives  rise  to  any  characteristic  alteration  in 
the  blood  picture. 

The  Sugar  Content  of  the  Blood. —  Kahler  has  recently  shown  that 
just  before  menstruation  there  occurs  what  he  terms  a  menstrual  hypergly- 
cemia, the  proportion  of  sugar  decreasing  again  with  the  onset  of  the  bleed- 
ing, and  reaching  its  minimum  at  the  end  of  the  period.  The  difference 
between  the  high  and  low  points  in  more  than  half  the  cases  was  as  much 
as  0.03  per  cent,  in  one  case  even  0.04  per  cent,  in  three  cases  0.02  per 
cent,  and  less  than  this  in  the  remainder.  Bearing  in  mind  that  the  normal 
amount  of  sugar  in  the  blood  is  only  a  little  over  o.  i  per  cent,  the  signifi- 
cance of  these  alterations  is  evident.  Kahler  looks  upon  the  occurrence  of 
this  menstrual  hyperglycemia  as  suggestive,  in  view  of  the  findings  of 
Chvostek  that  with  each  menstrual  period  there  occurs  an  acute  hypere- 
mia of  the  liver,  wuth  swelling  of  the  organ   (see  Chapter  XXV). 

Objective  Phenomena  of  Menstruation. —  The  beginning  of  men- 
struation is  usually  preceded  by  a  discharge  of  mucus  which  may  continue 
for  several  days.  On  the  appearance  of  the  blood,  in  what  might  be  called 
the  secondary  stage,  the  preliminary  discharge  becomes  gradually  mixed 
with  blood  until  it  appears  to  be  blood  alone.  In  the  third  stage  the  flow 
disappears  in  a  manner  the  reverse  of  its  gradual  appearance,  becoming 
lighter  in  color  and  less  in  quantity,  until  at  the  end  it  is  unstained  and 
reduced  merely  to  the  normal  secretions  of  the  parts. 

The  Menstrual  Discharge. —  In  addition  to  blood,  menstrual  dis- 
charge contains  a  greater  or  less  amount  of  mucin,  desquamated  epithelial 
cells,  bacteria,  and  granular  debris.  Owing  to  the  admixture  of  mucus,  it 
is  usually  even  more  viscid  than  blood  from  other  parts  of  the  body.  The 
characteristic  disagreeble  odor  is  partly  due  to  the  decomposition  of  blood 
elements  and  partly  to  the  activity  of  the  sebaceous  glands  of  the  vulva. 

Menstrual  blood,  according  to  Krieger,  differs  from  venous  blood  in  its 
high  water  content.  The  serum  of  the  former  contains  93.53  per  cent  of 
water,  while  venous  blood  contains  90.6  per  cent  water.  Krieger  quotes 
the  results  of  careful  chemical  analysis  made  of  menstrual  blood  by  Simon, 
Denis,  Vogel  and  Bouchardat,  as  follows : 


SIMON 

DENIS 

VOGEL 

BOUCHARDAT 

Water 

Solids 

785.00 
215.00 

825.00 
175.00 

839.00 
161 .00 

900.80 
99.20 

Analysis    of    the    solids    by    three    of    these    investigators    shows    the 
following : 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION 


95 


Fat. 

Blood  corpuscles 

Proteins 

Extractives 

Salts 

Mucin 


SIMON 


2.58 
120.40 

76.54 
8.60 


208. 12 


DENIS 


3-90 
64.40 

48.30 
I  .  10 

12.00 

45-30 


175.00 


HOUCIIARDAT 


2.21 

75-27 

0.42 

5-31 
16.97 


100.18 


Noncoagulability  of  Menstrual  Blood. —  By  far  the  most  interesting 
characteristic  of  menstrual  blood  is  its  non-coagulability,  1.  e.,  its  power  of 
retaining  its  fluidity  for  many  hours,  in  contrast  to  the  rapid  clotting  of 
blood  from  other  sources.  The  well  known  experiment  of  puncturing  the 
tissues  of  the  cervix  during  menstruation  brings  out  sharply  the  difference 
in  this  respect  between  the  menstrual  blood  and  that  of  the  body  generally. 
The  blood  which  oozes  from  the  puncture  clots  readily,  while  that  which 
comes  from  the  cervical  canal  remains  fluid. 

Reasons  for  Differences  of  Opinion. —  It  is  not  surprising  that  this 
property  of  menstrual  blood  has  given  rise  to  much  speculation  and  not  a 
little  scientific  investigation.  Unfortunately,  the  results  of  different  inves- 
tigators are  still  widely  at  variance,  partly,  no  doubt,  because  of  the  widely 
different  methods  which  have  been  employed  to  determine  the  coagulation 
time  of  blood.  Keller  enumerates  no  less  than  twenty-one  different  methods 
which  have  been  utilized  by  various  investigators.  He  himself  emphasizes 
the  advantages  of  Biirker's  method  and  the  improved  technic  of  Wright  in 
the  study  of  this  problem.  His  own  work  was  carried  out  by  the  technic 
described  by  Biirker. 

Importance  of  the  Problem. —  It  is  obvious  that  the  study  of  this 
question  is  of  the  greatest  importance,  not  only  in  connection  with  the  mech- 
anism of  normal  menstruation,  but  also  as  applied  to  the  explanation  of 
pathological  uterine  bleeding.  For  the  present,  however,  I  can  do  little 
more  than  sum  tip  the  findings  of  those  who  have  tried  to  explain  the  non- 
coagulability  of  normal  menstrual  blood. 

The  Role  of  the  Alkaline  Cervical  Mucus. —  One  of  the  earliest 
studies  of  the  subject  was  that  of  Birnbaum  and  Osten.  These  authors 
effectively  disposed  of  the  time  honored  belief  that  the  non-coagulability  of 
menstrual  blood  is  due  to  the  admixture  of  the  alkaline  cervical  mucus.  By 
mixing  this  mucus  experimentally  with  fibrin  producing  substances,  they 
were  able  to  show  that  not  only  was  coagulation  not  prevented,  but  that 
it  was  actually  accelerated.  From  further  experimentation  they  conclude 
that  menstrual  blood  remains  fluid  because  of  some  property  of  the  blood 
Itself.     They  suggest  that  operations  performed  during  menstruation  are 


96  MENSTRUATION  AND  ITS  DISORDERS 

apt  to  be  attended  with  more  hemorrhage  than  at  other  times  for  this 
reason:  i.  e.,  the  absence  from  the  blood  of  some  element  essentiaal  to  clot- 
ting. \\'hat  this  is  they  are  unable  to  say,  although  they  prove  that  the 
serum  of  menstrual  blood  has  the  power  to  inhibit  coagulation,  and  fur- 
thermore, that  the  coagulation  time  of  the  body  blood  is  increased. 

The  Possibility  of  a  Local  Factor  in  the  Endometrium. —  Cristea 
and  Denk  deny  the  correctness  of  the  last  named  finding  of  Birnbaum  and 
Osten,  i.  e.,  they  maintain  there  is  no  change  in  the  coagulation  time  of  the 
body  blood  during  menstruation.  They  believe,  on  the  other  hand,  that  the 
menstrual  blood  is  rendered  incapable  of  clotting  by  the  abstraction  from'  it 
by  the  uterine  mucosa  of  the  fibrin  ferment,  Hofnagel,  Bode,  and  Hart- 
mann  all  agree  with  Cristea  and  Denk  that  there  is  no  appreciable  change 
in  the  facility  with  which  body  blood  clots  during  menstruation. 

Schickele's  work  seems  to  indicate  that  extracts  made  under  proper  con- 
ditions from  the  uterine  tissues  possess  the  power  of  retarding  the  coagu- 
lation of  the  blood.  When  the  patient  had  suffered  with  abnormal  uterine 
bleeding,  extracts  of  the  uterine  mucosa  showed  a  striking  inhibitory  influ- 
ence on  coagulation.  This  work,  in  other  words,  suggests  that  the  non- 
coagulability  of  menstrual  blood  may  be  due  to  some  local  factor  In  the 
endometrium.  It  has  not,  however,  been  shown  that  this  inhibitory  prop- 
erty of  the  endometrium  is  present  only  at  the  menstrual  period.  More- 
over, as  Bell  pointed  out,  it  is  difficult  to  see  how  uterine  tissue,  and  espe- 
cially the  mucosa,  can  be  obtained  without  contamination  with  uterine  blood,  * 
and  of  course,  at  menstruation,  with  menstrual  blood. 

The  Possible  Influence  of  Changes  in  Coagulating  Time  of  Body 
Blood  at  Time  of  Menstruation. —  It  will  be  seen  from  the  foregoing 
that  the  study  of  the  problem  of  why  menstrual  blood  does  not  clot  is  quite 
intimately  bound  up  with  the  study  of  the  changes,  if  any,  which  occur  in 
the  coagulation  time  of  the  body  blood  at  the  time  of  menstruation.  The 
latter  question  has  been  recently  studied  by  Adler  and,  even  more  exten- 
sively, by  Keller,  who  concludes  that  menstruation  in  normal  women,  as 
well  as  those  suffering  with  various  forms  of  gynecological  disease,  exerts 
no  influence  on  the  coagulation  time  of  the  blood.  He  further  finds  that 
both  the  menopause  and  castration  are  similarly  without  effect. 

The  Absence  of  Fibrin  Ferment  in  Menstrual  Blood. — A  study  of 
blood  from  a  series  of  cases  of  hematocolpos  convinced  Bell  that  its  non- 
coagulability  was  due  to  the  absence  of  fibrin  ferment.  In  this  study, 
which  he  later  confirmed  by  experiments  with  normal  menstrual  blood,  he 
showed  also  that  neither  the  alkaline  cervical  mucus  nor  the  acid  vaginal 
secretion  were  in  any  way  instrumental  in  preventing  coagulation. 

The  Formation  of  Antithrombin  by  the  Endometrium, —  Finally, 
mention  may  be  made  of  the  interesting  results  obtained  by.Dienst,  who 
approached  the  subject  from  the  viewpoint  of  the  normal  physiology  of 
blood  coagulation.  For  the  latter  process  two  factors  are  essential  —  fibrin- 
ogen and  thrombin  or  fibrin  ferment.     The  first  of  these  exists  preformed 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  97 

as  one  of  the  proteins  of  blood  plasma.  The  latter,  on  the  other  hand,  is 
formed  from  thrombogen  or  prothrombin,  which  also  is  present  in  the  blood, 
and  thrombokinase,  another  substance  formed  from  the  destruction  of 
blood  and  tissue  cells.  For  this  last  transformation  the  presence  of  soluble 
calcium  salts  in  the  blood  stream  is  essential. 

Dienst  further  quotes  the  work  of  Howell  as  demonstrating  that  definite 
proportions  of  fibrinogen  and  thrombin  interact  to  form  the  fibrin  of  the 
clot,  and  that  the  thrombin  must  be  present  in  the  proportion  of  at  least  one 
to  two  hundred  and  fifteen  in  order  to  effect  clotting.  He  shows  further 
that  menstrual  blood  contains  the  same  amount  of  fibrinogen  as  other  blood, 
but  that  it  gives  rise  to  far  too  little  thrombin  or  fibrin  ferment  tO'  cause 
clotting.  To  this  fact  he  ascribes  the  non-coagulability  of  menstrual  blood. 
He  shows  clearly,  by  testing  blood  from  the  median  vein,  that  the  low 
thrombin  content  of  menstrual  blood  is  not  shared  by  the  body  blood 
generally. 

He  concludes  that  the  really  responsible  factor  is  the  formation  of  anti- 
thrombin  by  the  uterine  mucosa,  thus  counteracting  the  activity  of  the 
fibrin  ferment  and  preventing  clotting.  He  has  even  attempted  to  show 
that  the  excessive  uterine  bleeding  of  such  conditions  as  myomata  is  due  to 
an  excessive  formation  of  antithrombin  by  the  endometrium. 

The  Biological  Role  of  the  Endometrium  an  Important  Factor. 
—  Although  no  very  definite  conclusion  can  be  drawn  from  these  various 
investigations,  it  will  be  seen  that  the  trend  of  modern  work  is  to  fix  upon 
the  endometrium  a  biological  role  of  great  importance  in  the  mechanism  of 
normal  menstruation,  and,  among  other  things,  the  responsibility  for  the 
non-coagulability  of  normal  menstrual  blood.  Whether  this  is  due  to  an 
addition  to  or  a  subtraction  from  the  blood  of  some  important  element,  and 
what  this  element  is,  can  not  as  yet  be  definitely  stated. 


VIII 
LITERATURE 

Abler.     Zur  Physiologie  und  Pathologie  der  Ovarialfunktion.     Arch.  f.  Gyn., 

191 1»  95,  349- 
Bell.     The  Causes  of  the  Non-coagulability  of  Normal  Menstrual  Blood  and 

of  Pathological  Clotting.     Jour,  of  Path,  and  Bact.,  1913-14,  18,  462. 
Birnbaum  und  Osten.     Gerinnung  des  Blutes  wahrend  der  Menstruation. 

Arch.  f.  Gyn.,  1906,  80,  373. 
Blumenthal.     Ergebnisse  der  Blutuntersuchungen  in  der  Geburtshilfe  und 

Gynakologie.     Hegars  Beitrage  z.  Geb.  u.  Gyn.,  1908,  61,  614. 
DE  Boismont.     De  la  menstruation,  etc.     Paris,  1842. 
Carnot  und  Deflandre.     Schwankungen  in  der  Zahl  der  Roten  Blutkor- 

perchen  bei  der  Erau  wahrend  der  Menstruation.     Zentralb,  f.  Gyn., 

1910,  34,  335. 


98  MENSTRUATION  AND  ITS  DISORDERS 

Cantoni.  Ueber  die  Blutveranderungen  wahrend  der  Menstruation.  Arch. 
f.  Gyn.,  1913,  99,  541. 

Chisholm.  Menstrual  Molimina.  J.  Obst.  and  Gyn.  Brit.  Emp.,  1913,  23, 
288. 

Cristea  und  Denk.  Ueber  Blutgerinnung  wahrend  der  Menstruation.  Wien. 
Khn.  Wochensch.,  1910,  23,  234. 

DiENST.  Die  Ursache  fiir  die  Gerinnungsfahigkeit  des  Blutes  bei  der  Men- 
struation.    Miinch.  Med,  Wochensch.,  1912,  59,  2799. 

Dirks.  Ueber  Veranderungen  des  Blutbildes  bei  der  Menstruation,  bei  Men- 
sitruationsanomahen  und  in  der  Menopause.     Arch.  f.  Gyn.,  1912,  97, 

583- 
Emmett,  T.  a.     Text  Book  of  Gynecology.     Philadelphia,  1880. 
Fehling.     Lehrbuch  der  Frauenkrankheiten.     1900. 
Foster.     Periodicity  and  Duration  of  Menstrual  Flow.     N.  Y.  Med.  J.,  1889, 

49,  610. 
Freind.     Emmenologia.     London,  1729. 
Galen  Claudius.     Opera.     Lipsiae,  1828. 

Gebhard.     Die  Menstruation.     Veits  Handb.  d.  Gyn.,  1898,  v.  3. 
Giles.     The  Cyclical  or  Wave  Theory  of  Menstruation,  with  Observations  on 

the  Variations  in  Pulse  and  Temperature  in  Relation  to  Menstruation. 

Tr.  Obst.  Soc.  Lond.,  1897,  39,  115. 
GiLLETT,  Wheeler,  and  Yates.     Material  Lost  in  Menstruation.     Amer.  J. 

Physiol.,  1918,  47,  25. 
Goodman.     The  Cyclical  Theory  of  Menstruation,     Am.  J.  Obst.,  1876,  11, 

673- 
GuMPRicH.     Der  Einfluss  der  Menstruation  auf  das  Blutbild  bei  Gesunden 

Individuen.     Beitr.  z,  Geb.  u.  Gyn.,  1913-14,  19,  435. 
Hayem.     Traite  d'  hematologic.     Paris,  1904. 

Hennig.     Ueber  die  Temperatur  Menstruierender.     Heidelberg,  1882. 
Hippocrates.     Opera  Omnia. 
Hoppe-Seyler.     Ueber   den   Blutverlust   bei   der   Menstruation.     Zeitsch.    f. 

Physiol.  Chemie,  1904,  42,  545. 
Howell.     Text-book  of  Physiology.     Phila.,  191 5. 
Jacobi.     The  Question  of  Rest  for  Women  During  Menstruation.     New  York, 

1877. 
Johnstone.     Clinical  Importance  of  the  Menstrual  Wave.     Trans.  Amer.  Gyn, 

Soc,  1896,  21,  57. 
Kahler.     Ueber  den   Einfluss  der  Menstruation  auf   den   Blutzuckergehalt. 

Wien.  Klin.  Wochensch.,  1914,  27,  417. 
Keller.     Blutgerinnungszeit  und  Ovarialfunktion.     Arch.  f.  Gyn.,  1912,  97, 

540. 
Kersch.     Ueber  Veranderungen  der  Korpertemperatur  durch  den  Menstrua- 

tionsprozess.     Heidelberg,  1882. 
Ketcham.     The  Hygiene  of  Menstruation.     Jour.  Indiana  State  Med.  Assoc, 

191 1,  4,  224. 
King.     Possible  Periodic  Variations  in  Extent  of  Kneejerk  in  Women.    Amer. 

J.  Physiology,  1917,  42,  607. 
Periodic  Cardiovascular  and  Temperature  Variations  in  Women,    Amer. 

J.  Physiology,  1914,  34,  203, 


CLINICAL  CHARACTERISTICS  OF  NORMAL  MENSTRUATION  99 

KiscH.     Sexual  Life  of  Women  in  its  Physiological,  Pathological  and  Hygienic 

Aspects.     Trans,  by  M.  E.  Paul.    1910. 
Krieger.     Die  Menstruation.     Eine  Gynakologische  Studie.     Berlin,   1869. 
Krutsciienoff.     Recherches  sur  les  variations  des  globules  sanguins  au  cours 

de  la  menstruation.     Diss.,  Paris,  1909. 
MuRLiN  AND  Bailey.     Relation  of  Sex  Glands  to  Metabolism.     Surg.  Gyn.  and 

Obst.,  1917,  25,  332. 
Lahille.     Quantity  of  Blood  Lost  at  Menstruaition.     Ann.  de  Gyn.  et  d'  Obst., 

1917,  1^,  535- 
Martin.     Die  Krankheiten  der  Weiblichen  Adnexorgane.     1899. 
Mosher.     Normal  Menstruation  and  Some  of  the  Factors  Modifying  it.    Bull. 

Johns  Hopk.  Hosp.,  1901,  12,  178. 
VON  Ott.     Gesetz  der  Periodizitat  der  Physiologischen  Funktionen  im  Weib- 
lichen Organen.     Zentralb.  f.  Gyn.,  1890,  14  (suppl.)  31. 
PoGGi.     La  funzione  mestruale,  etc.     Policlinico,  1899,  6,  i. 
PoLZL.     Ueber   Menstruelle  Veranderungen  des   Blutgefundes.     Wien,   Klin. 

Wchnsch.,  1910,  2'^,,  238. 
Raciborski.     Traite  de  la  menstruation.     Paris,  1868, 
Reinl.     Die  Wellenbewegung  der  Lebensprocesse  des  Weibes.     Volkmanns 

Samml.  Klin.  Vortrage,  1884,  Gynak.,  no.  67,  1737. 
Sanes.     Menstrual  Statistics :    a  Study  Based  on  4500  Menstrual  Histories. 

Amer.  J.  Obst.,  1916,  73,  93. 
Schickele.     Wirksame  Substanzen  in  Uterus  und  Ovarlen.     Miinch.   Med. 

Wchnschr.,  1911,  58,  123. 
Schmotkin.     Klinische  Untersuchungen  iiber  die  Menstruation  bei  Gesunden 

Individuen.     Arch.  f.  Gyn.,  1912,  97,  495. 
Stephenson.     On  the  Menstrual  Wave.     Amer.  J.  Obst.,  1882,  15,  287. 
ToBLER.     Ueber  den  Einfluss  der  Menstruation  auf  den  Gesamtorganismus  der 

Frau,  auf  Grund  von  1000  Beobachtungen.     Monats.  f.  Geb.  u.  Gyn., 

1905,  22,  I. 
ViviLLE.     Die  Beziehungen  der  Menstruation  zum  Allgemeinorganismus  bei 

Gynakologischen  Erkrankungen.     Arch.  f.  Gyn.,  1912,  97,  511. 
WiESSNER.     Ueber  Blutdruckmessungen  wahrend  der  Menstruation  under  der 

Schwangerschaft.     Zentralb.  f.  Gyn.,  1899,  23,  1335. 
Zuntz.     Untersuchungen  iiber  den  Einfluss  der  Ovarien  auf  dem  Stofifwechsel. 

Arch.  f.  Gyn.,  1906,  78,  106. 


CHAPTER  IX 
PUBERTY  AND  THE  ONSET  OF  MENSTRUATION 

General  Considerations. —  Puberty  is  one  of  the  critical  periods  in 
the  Hfe  of  woman.  It  marks  the  transition  from  girlhood  to  womanhood, 
and  is  characterized  by  certain  anatomical  and  physiological  changes  which 
indicate  the  awakening  of  the  sexual  apparatus  to  activity.  It  would  seem 
that  in  both  sexes  the  reproductive  organs,  not  being  essential  to  life,  are 
the  last  to  take  up  their  characteristic  functions.  Up  to  the  age  of  puberty, 
all  the  organs  of  the  body  show  a  gradual  development  —  except  the  gen- 
erative organs.  Their  awakening  marks  the  beginning  of  what  is  virtually 
a  new  existence  for  the  girl.  The  growth  of  the  organism  up  to  this  time 
seems  to  be  the  result  of  the  potential  energy  —  "  the  primitive  impulse  "  — 
derived  from  the  blending  of  the  ovum  and  the  spermatozoon.  With  the 
awakening  of  the  sex  organs,  however,  it  seems  that  the  burden  of  further 
growth  and  development  is  taken  up  by  them.  Not  only  are  they  responsible 
for  the  appearance  of  the  so-called  secondary  sexual  characteristics,  but  they 
also  exert  a  profound  influence  on  the  physical  and  mental  growth  of  the 
individual. 

General  Body  Changes  at  Puberty. —  At  the  age  of  puberty,  there 
occurs  a  rather  sudden  and  usually  striking  acceleration  in  the  development 
of  the  girl.  Up  to  this  period  there  are  only  slight  differences  in  the  gen- 
eral development  of  the  two  sexes,  the  girl  being  often  just  as  angular  and 
"  boyish  "  in  contour  as  the  boy  himself.  There  is  no  noteworthy  difference 
between  the  external  form  of  the  male  and  female  bodies,  the  general  out- 
line of  the  skeleton,  or  even  in  the  pelvis.  With  the  onset  of  puberty,  how- 
ever, the  figure  of  the  girl  begins  to  take  on  the  characteristic  outline  of  the 
woman  —  the  hips  become  more  rounded,  the  breasts  fuller  and  more 
prominent,  while  the  nipples  also  become  larger.  In  some  cases  the  hyper- 
trophy of  the  breasts  may  become  pathologically  excessive,  constituting  the 
so-called  "diffuse  virginal  hypertrophy"  (Bloodgood).  As  a  result  of  a 
general  deposit  of  fat,  the  lines  of  the  entire  figure  become  softer  and  more 
rounded.  A  growth  of  hair  appears  on  the  vulva,  mons  veneris,  and  in  the 
axillary  spaces.  The  change  of  voice,  so  characteristic  of  puberty  in  boys, 
is  usually  less  marked  in  girls. 

Changes  in  Reproductive  Organs. —  In  addition  to  the  above,  there 
occur  certain  well  defined  anatomic  changes  in  the  reproductive  organs 
themselves.  The  uterus  becomes  larger  and  also  undergoes  a  characteristic 
change  in  shape.     While  the  uterus  of  the  female  child  is  somewhat  flat- 

100 


PUBERTY  AND  THE  ONSET  OF  MENSTRUATION  101 

tened,  that  of  the  young  woman  shows  a  fundus  with  decidedly  convex 
walls.  Furthermore,  there  is  a  striking  change  in  the  proportion  existing 
between  the  cervix  and  the  fundus.  In  the  young  child  the  cervix  makes 
up  something  like  two  thirds  of  the  entire  uterus;  in  the  young  woman, 
before  childbirth,  the  fundus  has  increased  to  such  an  extent  that  it  makes  up 
at  least  one  half  of  the  entire  uterus ;  while  after  childbirth  the  fundus 
occupies  usually  two  thirds  of  the  entire  organ.  The  tubes  and  ovaries, 
which  in  the  young  child  are  undeveloped,  also  increase  in  size  at  the  time 
of  puberty. 

Important  changes  take  place,  also,  in  the  external  genitalia.  The  mons 
veneris  become  much  more  prominent,  owing  to  the  deposit  of  adipose 
tissue,  and  as  "already  stated,  its  skin  becomes  covered  with  hair.  The  labia 
majora,  which  are  very  rudimentary  in  the  young  child,  become  much  more 
prominent  owing  to  a  deposit  of  fat,  and  a  hairy  growth  appears  on  their 
external  surfaces.  As  a  result  of  this  increase  in  size  of  the  labia  majora, 
the  labia  minora  become  more  or  less  concealed,  in  contrast  to  their  prom- 
inence in  the  vulva  of  the  young  child. 

Psychic  Changes. —  A  radical  transformation  takes  place  in  the 
psyche  of  the  girl  at  this  period,  for  now  she  becomes  conscious,  for  the  first 
time,  of  the  distinction  between  the  sexes.  The  exact  effect  of  the  new 
impulse  in  the  girl's  life  varies  according  to  the  temperament  of  the  girl, 
her  environment  and  associates,  and  other  such  factors.  A  certain  element 
of  shyness  in  the  presence  of  the  other  sex,  a  tendency  to  daydreaming,  a 
strain  of  romanticism  —  these  are  among  the  numerous  manifestations  often 
observed. 

Physiological  Changes. —  The  physiological  changes  which  occur  at 
the  time  of  puberty  are  even  more  striking  than  the  anatomic.  Most  im- 
portant among  them  are  the  appearance  of  menstruation  and  ovulation. 
It  is  sometimes  said  that  the  onset  of  menstruation  marks  the  beginning  of 
puberty ;  strictly  speaking,  however,  this  is  not  correct,  for  menstruation  is 
only  one  of  the  phenomena  which  make  up  this  period  of  transition. 

Menstruation  Only  One  of  the  Manifestations  of  Puberty. —  Table  I 
gives  the  results  of  an  interesting  study  in  this  connection  made  upon  3279 
girls  by  Dr.  Mary  A.  Hodge,  of  the  Public  Athletic  League  of  Baltimore, 
under  the  supervision  of  Dr.  William  A.  Burdick,  the  head  of  the  League. 
The  criteria  of  pubescence  were  considered  to  be,  not  the  mere  appearance 
of  the  first  menstrual  flow,  but  such  changes  as  the  deposit  of  subcutaneous 
fat,  with  the  appearance  of  a  waist  line,  beginning  enlargement  of  the 
breasts,  the  appearance  of  axillary  hair,  etc. 

The  prepubescent  group,  in  whom  such  changes  had  not  yet  appeared,, 
embraces  girls  of  various  ages,  the  oldest  being  22  years.  The  adolescent 
group  comprises  those  in  whom  menstruation  was  present. 

The  following  table  gives  the  number  of  girls  of  each  age  examined,  the 
entire  series  being  subdivided  into  the  three  groups  designated  as  "  pre- 
pubescent," "  pubescent,"  and  "  adolescent,"  according  to  the  criteria  just 


102 


MENSTRUATION  AND  ITS  DISORDERS 


mentioned.  The  percentage  figures  refer  to  the  proportionate  number  of 
girls  at  each  age  classifiable  under  one  or  other  of  the  three  types.  For 
example,  all  of  the  23  girls  of  6^  years,  or  100  per  cent,  were  prepubescent. 
On  the  other  hand,  there  was  i  girl  of  lyi  (i.i  per  cent)  who  was  also 
classified  as  prepubescent. 


Table  I 


AGE 

PREPUBESCENT 

PUBESCENT 

ADOLESCENT 

AGE 

No. 

Per  cent 

No. 

Per  cent 

No. 

Per  cent 

5 

I 

100. 

5 

Si 

I 

100. 

5i 

6 

14 

100. 

6 

6i 

23 

100. 

6i 

7 

33 

100. 

7 

7* 

46 

100. 

7i 

8 

60 

100. 

8 

8i 

64 

100. 

84 

9 

79 

100. 

9 

9i 

108 

99.0 

I 

I.O 

9i 

10 

112 

100. 

0 

0. 

10 

loi 

127 

96.2 

4 

3-0 

I 

0.7 

10* 

II 

114 

92.6 

9 

7-3 

0 

0. 

II 

11* 

103 

78.6 

25 

19.0 

3 

2.2 

III 

12 

90 

66.1 

39 

28.6 

7 

5-1 

12 

I2i 

88 

57-5 

45 

29.4 

20 

13.0 

I2i 

13 

61 

37-8 

01 

37-8 

39 

24.2 

13 

i3i 

38 

23-7 

/o 

30.6 

73 

45-6 

i3i 

14 

24 

13-4 

5  '  .28.7 

103 

57-8 

14 

I4i 

7 

4-7 

- 

19.7 

III 

75-5 

144 

15 

4 

2.7 

22 

I5-I 

119 

82.0 

15 

i.Si 

2 

1-3 

II 

7-1 

141 

91.4 

i5i 

16 

2 

1.4 

6 

4.2 

133 

94-3 

16 

161 

0 

0.0 

4 

3-0 

126 

96.9 

i6i 

17 

I 

I.I 

98 

97-9 

17 

m 

I 

1 .1 

87 

98.8 

i7i 

m+ 

I  (22  yr) 

0.1 

658 

99-7 

i7i+ 

1204 

356 

1719 

To.  3279 

Age  at  Which  Menstruation  Appears. —  The  age  at  which  menstrua- 
tion first  appears  is  subject  to  much  variation.  It  is,  furthermore,  sup- 
posedly influenced  by  climate,  race,  and  other  factors.  The  most  complete 
statistics  regarding  the  age  of  the  onset  which  have  been  compiled  in  this 
country  are  those  of  Dr.  George  J.  Engelmann.  This  observer  studied 
over  10,000  cases,  from  this  standpoint,  in  American  born  women  alone. 


PUBERTY  AND  THE  ONSET  OF  MENSTRUATION  103 

He  found,  first  of  all,  that  the  American  born  woman  is  more  precocious  with 
regard  to  the  onset  of  menstruation  than  the  women  of  other  countries  in 
the  same  zone.  His  statistics  showed  that  the  average  age  of  onset  in  the 
United  States  and  Canada  is  13.9  years,  while  in  the  corresponding  tem- 
perate zone  of  Europe,  it  is  15.5  years.  Again,  he  found  that  the  native 
American  girl  is  more  precocious  than  the  American  born  girl  of  foreign 
parents,  although  the  latter,  even  in  the  first  generation,  closely  approxi- 
mates the  American  girl  of  American  parents.  Racial  characteristics,  he 
finds,  fade  away  very  rapidly.  While  the  age  of  puberty  in  Germany  is  15.5 
to  16  years,  and  in  Ireland  15.3  years,  in  the  girl  born  in  America  of  German 
or  Irish  parentage  it  is  only  14.5  years.  Only  the  Canadians  and  French 
seem  to  be  exceptions  to  this  general  rule,  for  while  they  begin  to  men- 
struate at  14  and  15  in  their  native  land,  when  born  in  this  country  they 
are  more  precocious  than  the  Americans  of  the  same  class,  13.7  years  being 
the  average  age.  Climate,  therefore,  seems  to  have  no  influence,  and  race 
very  little.  The  statistics  of  Currier,  obtained  from  a  much  smaller  series 
of  cases,  give  the  average  of  the  first  menstruation  in  this  country  as  14.5 
years.  Among  these,  those  of  American  parentage  show  an  average  of 
14. 1,  Irish  14.75,  Italian  1^.6,  German  15.6,  French  12.6,  English  14, 
Swedish  16.25,  Austrian  15.6,  Canadian  14,  Scotch  16,  Danish  17,  Russian 
19,  Szi/iss  19,  Polish  16,  and  Greek  13.  In  Bohemia  the  age  of  menstrua- 
tion is  between  15  and  16,  according  to  Necos  (quoted  by  Lenz). 

The  age  of  onset  of  menstruation  among  Indians  has  been  studied  by 
A.  B.  Holder.  According  to  this  author,  it  is  not  easy  to  learn  the  age  of 
puberty  among  Indians,  inasmuch  as  it  is  a  custom  in  most  tribes  for  the 
girls  to  marry  before  the  menses  appear.  It  might  be  believed  that  the 
early  age,  and  consequent  sexual  stimulation,  together  with  the  entire 
absence  of  modesty  in  action,  thought,  and  conversation,  would  tend  to 
cause  precocious  menstruation,  and  the- statistics  of  Holder  seem  to  confirm 
this  impression.  Even  in  the  girls  who  are  in  school  until  after  puberty, 
menstruation  seems  to  appear  earlier  than  in  white  girls  in  the  same  latitude. 
The  cases  upon  which  Holder's  report  is  based  were  observed  in  an  agency 
school,  under  his  own  personal  supervision.  The  average  of  this  limited 
number  of  cases  is  12.91  years,  and  is  in  accord  with  the  opinion  of  the 
other  physicians  in  charge  of  the  Indians  on  the  government  reservations. 

The  question  of  the  beginning  of  menstruation  in  the  Japanese  and 
Chinese  has  been  studied  by  M.  Yamasaki.  There  are  five  distinct  races 
inhabiting  Japan  —  the  Japanese,  the  Ainos,  the  Koreans,  the  Chinese,  and 
the  natives  of  the  country  in  Formosa.  There  were  4861  Japanese  women 
studied  by  Yamasaki.  The  average  age  of  the  beginning  of  menstruation 
was  found  to  be  14.8  years.  The  earliest  menstruation  occurred  at  9  years 
and  7  months ;  the  latest  at  21  years  and  10  months.  From  the  collected  ob- 
servations of  14  authors,  upon  26,082  Japanese  women,  the  average  age  was 
15.05  years.  The  Chinese  women  observed  were  all  residents  of  Formosa, 
who  had  emigrated  from  China  long  previously.     There  were  135  cases, 


104  MENSTRUATION  AND  ITS  DISORDERS 

the  earliest  menstruation  being  ii  years,  and  the  average  17  years.  It  will 
thus  be  seen  that,  although  the  climate  of  Formosa  is  warmer  than  that  of 
Japan,  the  first  menstruation  occurred  later  than  in  Japan.  Of  the  Korean 
women  there  were  184,  and  the  average  age  of  onset  was  17  years.  Here 
the  beginning  of  puberty  was  even  later  than  among  the  Japanese,  although 
the  climate  is  warmer  than  that  in  which  the  Japanese  races  live,  and  colder 
than  that  of  Formosa.  Among  the  Ainos,  84  women  were  examined.  The 
average  here  was  15  years.  On  the  whole,  therefore,  it  will  be  seen  that 
this  extensive  study  led  to  a  conclusion  the  opposite  of  that  generally  held 
with  reference  to  the  influence  of  climate.  The  general  opinion  seems  to  be 
that  race  and  manner  of  life  have  a  greater  influence  on  the  beginning  of 
puberty  than  climate.  Four  races  here  show  very  little  difference,  although 
their  mode  of  life  varies  greatly.  For  example,  the  Chinese  women  live 
entirely  in  the  house,  while  the  Ainos  hunt  and  work  in  the  field. 

The  menstrual  history  of  Egyptian  girls  was  studied  in  275  cases  by 
Elgood,  the  girls  all  attending  a  boarding  school  for  natives  in  Cairo  and 
being  between  the  ages  of  6  and  16.  No  child  began  to  menstruate  before 
12,  only  8  at  this  age,  and  in  the  majority  the  onset  occurred  at  13  or  after. 
Some  did  not  menstruate  until  the  age  of  16  or  even  later.  The  examination 
of  the  girls  in  three  of  the  boarding  schools  in  Egypt  showed  that  of  295 
girls,  between  6  and  1 1  years  of  age,  not  one  had  menstruated ;  of  143, 
between  the  ages  of  12  and  18,  81  had  menstruated  and  62  had  not. 

In  the  study  of  624  cases  from  the  arctic  zone,  mostly  arctic  Indians 
and  Esquimaux,  Engelmann  found  the  average  age  of  the  onset  of  men- 
struation to  be  14.6  years.  In  2733  cases  from  the  subtropical  region  of 
south  Asia  (18°  and  23°  N.  lat.),  Robertson  found  the  average  to  be  12.9 
years.  However,  in  the  tropical  zones  themselves,  where  we  might  expect 
the  age  of  onset  to  be  very  low,  the  study  of  1593  cases  of  Campbell, 
Robertson,  and  others,  has  shown  the  average  age  to  be  15.8  years.  These 
cases  were  collected  from  Siam  (13°  N.  lat.).  Cochin  China  (11°  and 
17°  N.  lat),  Barbados  and  Demerara  (6°  and  13°  N.  lat),  Batavia  (8°  S. 
lat),  Somaliland  (0°  and  10°),  and  Bogasland  (0°  and  10°). 

Factors  Influencing  Age  of  Onset  of  Menstruation. —  To  sum  up 
these  various  statistics,  therefore,  it  will  be  noted  that  it  is  not  easy  to  draw 
deductions  concerning  the  influence  of  race  and  climate.  It  seems  to  be 
true,  however,  that,  contrary  to  the  general  impression,  climate  does  not 
exert  a  powerful  influence  upon  the  age  of  onset.  It  has  usually  been 
believed  that  menstruation  appears  at  a  much  earlier  age  in  warm  countries 
than  in  cold,  but  as  has  been  seen,  this  is  certainly  not  an  invariable  rule. 
The  influence  of  race  also  seems  to  be  less  important  than  generally  believed, 
and  the  same  thing  applies  to  the  manner  of  life. 

Individual  factors  are  probably  much  more  important  in  influencing  the 
age  of  onset  than  such  general  factors  as  we  have  considered.  The  men- 
tality of  the  girl,  her  surroundings,  her  education,  her  temperament,  etc., 
all  stand  out  prominently  as  factors  which  determine  precocity  in  the  appear- 


PUBERTY  AND  THE  ONSET  OF  MENSTRUATION  105 

ance  of  the  menses.  Astruc,  one  of  the  old  authors  on  the  subject,  men- 
tions "Among  the  things  which  sooner  bring  the  menses  are  fever,  coition, 
drinking  much,  violent  emotion,  vomiting,  sneezing,  anger,  the  hysterical 
passion,  the  suppression  of  a  customary  evacuation,  and  emmenagogues. 
Those  things  by  which  the  menses  are  retarded  are  immoderate  cold,  sorrow, 
a  sudden  fright,  too  great  evacuation,  incrassating  diet,  acrudity  of  humours, 
acids,  and  astringent  medicines."  The  importance  of  some  of  these  factors, 
it  will  be  seen,  is  based  upon  the  old  "  plethora  theory  "  of  the  causation  of 
menstruation,  which  Astruc  held,  in  common  with  most  of  the  authors  of  his 
time.  In  addition  to  the  above,  it  may  be  stated  that  overnutrition,  exces- 
sive meat  diet,  and  intense  mental  activity  are  among  the  factors  which  tend 
to  accelerate  the  menstrual  onset.  On  the  other  hand,  simple,  regular  and 
moderate  diet,  and  avoidance  of  excessive  nerve  strain  or  mental  work  are 
retarding  factors. 

Cause  of  Puberty. —  The  fact  that  at  the  time  of  puberty  there  is  a 
rather  sudden  acceleration  of  development  of  the  generative  organs,  and  at 
the  same  time  a  striking  change  in  parts  of  the  body  not  directly  connected 
with  the  generative  tract  —  the  so-called  secondary  sexual  characteristics  — 
is  the  basis  for  the  view  which  many  have  supported  that  these  sex  stigmata 
are  the  direct  cause  of  the  awakening  of  the  reproductive  organs  to  activity. 
According  to  Roberts  (quoted  by  Biedl)  there  are  primitive  people  in  Russia 
and  in  India  who  attribute  these  various  sexual  distinctions  to  the  external 
genitalia,  and,  in  the  case  of  women,  to  the  breasts.  The  Russian  Skopzi, 
according  to  this  author,  believe  that  women  are  rendered  sterile  by  removal 
of  the  breasts  and  external  genital  organs.  The  old  dictum,  "  Propter 
uterum  solum  mulier  est  quod  est,"  or,  in  its  revised  form,  "  Propter 
ovarium  solum  mulier  est  quod  est,"  represents  the  same  theory  to  which 
Virchow  later  gave  expression  in  these  words :  "  Woman  is  woman  by 
reason  of  her  generative  glands.  All  the  peculiarities  of  her  body  and 
mind,  everything,  in  fact,  which  in  the  true  woman  we  admire  and  revere 
as  womanly,  is  dependent  upon  the  ovary."  By  the  secondary  sexual  char- 
acteristics John  Hunter  indicated  all  those  distinctive  sex  manifestations 
which  are  not  directly  concerned  with  the  processes  of  reproduction,  includ- 
ing under  this  grouping  such  changes  as  appear  in  the  mammary  glands,  the 
skeletal  growth,  the  distribution  of  adipose  tissue,  the  size  of  the  larynx,  etc. 

There  are  some  investigators,  notably  Tandler  and  Gross,  who  believe 
that  the  secondary  sexual  characteristics  are  nothing  more  than  character- 
istics of  the  species,  and  that  they  have  no  direct  relationship  with  the  organs 
of  generation.  As  evidence  in  support  of  this  theory,  the  fact  is  brought 
forth  that  even  in  fetuses  and  new  born  infants,  long  before  the  awakening 
of  the  sexual  glands  themselves,  a  number  of  characteristic  differences  be- 
tween the  sexes  are  already  apparent.  For  instance,  there  are  differences 
in  the  size  of  the  hands  and  feet,  the  body  weight,  the  size  and  weight  of 
the  brain,  and  the  bony  structure  of  the  pelvis.  It  has  been  pointed  out, 
however,  that  this  evidence  is  far  from  conclusive,  inasmuch  as  at  this  early 


106  MENSTRUATION  AND  ITS  DISORDERS 

age,  the  primary  sex  glands  —  the  ovary  and  the  testis  —  are  ah-eady  well 
differentiated,  and  it  is  impossible  to  exclude  their  influence  in  the  produc- 
tion of  the  changes  above  mentioned.  On  the  other  hand,  there  is  much 
evidence,  such  as  that  derived  from  a  study  of  the  effects  of  prepubertal 
castration,  to  justify  the  generally  accepted  theory  that  the  changes  of 
which  we  are  speaking  are  dependent  upon  the  presence  of  the  genital 
gland,  and  that  they  are  correctly  spoken  of  as  "  secondary  sexual  character- 
istics." 

Essential  as  the  ovary  is  for  a  full  development  of  the  secondary  sexual 
characteristics,  it  must  not  be  assumed  that  it  is  the  only  structure  which 
exerts  an  influence  in  the  production  of  the  various  changes  included  under 
that  head.  As  we  shall  see  in  a  later  chapter  (Chapter  XXIV),  there  is  a 
most  intimate  correlation  of  function  between  the  ovary  and  certain  other 
ductless  glands,  the  most  important  of  which  are  the  thyroid,  the  thymus, 
the  suprarenal,  the  pituitary  and  the  pineal  body.  All  of  these  structures 
have  a  possible  auxiliary  influence  in  the  production  of  the  secondary 
sexual  characteristics.  It  is  probably  correct  to  say  that  when  the  correla- 
tion of  function  of  these  various  organs  with  internal  secretions  (i.  e.,  the 
ovary,  thyroid,  thymus,  suprarenal,  pituitary  and  pineal)  is  a  harmonious 
one,  the  anatomic  and  physiologic  changes  so  characteristic  of  puberty  appear 
in  a  normal  manner.  When,  on  the  other  hand,  there  is  a  break  somewhere 
in  the  functional  chain  represented  by  these  organs,  there  is  apt  to  be  some 
sort  of  abnormality  of  puberty,  either  in  its  character  or  in  the  time  of  its 
onset. 


LITERATURE 

BiEDL.     Innere  Sekretion.     1910. 

Christopher.  Nature  and  Management  of  Puberty.  Am.  Gyn.  and  Obst.  ]., 
1898,  13,  I. 

Elgood.  Age  of  Onset  of  Menstruation  in  Egyptian  Girls.  J.  Obst.  and  Gyn. 
Brit.  Emp.,  1909,  16,  242. 

Falta.     Die  Erkrankungen  der  Blutdriisen.     191 3. 

Grusdeff.     Eintritt  der  Geschlechtsreife.     Centralb.  f.  Gyn.,  1894,  18,  568. 

Heinricius.  Eintritt  der  Menstruation  bei  3500  Weiben  in  Finnland.  Cen- 
tralb. f.  Gyn.,  1883,  7,  72. 

Holder.     The  Age  of  Puberty  of  Indian  Girls.     Amer.  J.  Obst.,  1890,  23,  1074. 

JouBERT.  The  Supposed  Influence  of  Tropical  Climate  on  Menstruation. 
Indian  M.  Gaz.,  Calcutta,  1895,  30,  129. 

Krieger.     Die  Menstruation.     Eine  Gynakologische  Studie.     Berlin,  1869. 

Leicester.  Menstruation  in  Europeans,  Eurasians,  and  East  Indians  in  India. 
J.  Obst.  and  Gyn.  Brit.  Emp.,  1910,  17,  414. 

Rossi  DoRiA.  Uebcr  das  Alter  der  Ersten  Menstruation  in  Italien.  Arch.  f. 
Gyn.,  1908,  86,  505. 


PUBERTY  AND  THE  ONSET  OF  MENSTRUATION  107 

RouTH.     Influence  of  Tropical  Climates  upon  Functioning  Female  Generative 

Organs  in  Health  and  Disease.     J.  Trop.  Med.  and  Hyg.,  1908,  11,  369. 
ScHAFFER.     Ueber  das  Alter  des  Menstruationsbeginn.     Arch.  f.  Gyn.,  1909, 

84,  657. 
Tandler.     Untersuchungen  an  Skopzen.     Wien.  klin.  Woch.,  1908,  21,  227. 
Tandler  und  Gross.     Einfluss  der  Kastration  auf  den  Organismus.     Wien. 

Klin.  Woch.,  1907,  20,  1596. 
Yamasaki.     Ueber    den    Beginn    der    Menstruation    bei    Japanerinnen,    etc. 

Ztschr,  f.  Gynak.,  1909,  ^^,  1296. 


CHAPTER  X 

THE  HYGIENE  OF  PUBERTY 

The  Role  of  the  Mother. —  It  would  certainly  seem  necessary  to 
emphasize  the  very  great  importance  of  a  proper  supervision  and  regime 
at  this  critical  period  in  the  life  of  the  girl.  As  she  unfolds  into  woman- 
hood she  is  susceptible  to  all  of  the  many  influences,  big  and  little,  of  her 
environment  and  association.  To  mould  her  into  a  healthy  type  of  woman 
it  is  essential  that  these  various  influences  be  of  a  beneficent  character. 
Especially  important  is  it  that  the  atmosphere  of  the  home  be  of  the  proper 
sort.  There  can  be  no  question  that  it  is  the  mother,  especially,  who'  exerts 
the  most  profound  and  permanent  influence  upon  the  character  and  tem- 
perament of  the  growing  girl,  and  that  it  is  she,  especially,  who  can  be  of 
the  greatest  service  to  her  daughter  at  this  trying  period  in  the  latter's  life. 
The  truth  of  this  is  well  exemplified  in  the  many  unfortunate  cases  in  which 
young  girls  are  left  motherless.  There  is  nothing  more  beautiful  than  the 
mutual  love  and  confidence  of  mother  and  daughter  in  the  ideal  home. 
Happy  is  the  girl  with  a  mother  to  whom  she  can  gO'  for  counsel  in  the 
many  perplexities  which  are  apt  to  arise  during  this  transitional  period  of 
her  life!  The  girl  approaching  this  period  should  be  prepared  by  her 
mother  for  the  advent  of  the  menstrual  process,  which  otherwise  might 
frighten  and  distress  her.  Inasmuch  as  mothers  and  daughters  differ  so 
much  in  the  character  of  the  relationships  which  they  bear  to  one  another,  it 
is  obvious  that  this  enlightenment  of  the  girl  will  be  conveyed  in  various 
ways,  if  at  all. 

Instruction  in  Sex  Hygiene. —  No  one  can  quite  take  the  place  of  the 
mother  in  instructing  her  daughter  in  the  simple  and  beautiful  truths  of  the 
reproductive  life  and  its  various  manifestations.  When,  however,  such 
home  instruction  is  out  of  the  question,  as  a  result  of  ignorance  or  other 
incapacity  on  the  part  of  the  parent,  there  is  a  legitimate  field  for  the  activity 
of  various  agencies  now  interested  in  "  sex  education  "  of  young  people. 
That  such  instruction  should  come  only  from  those  who  are  peculiarly  fitted 
for  it,  and  who  at  the  same  time  are  sane  enough  to  appreciate  that  there 
may  be  an  element  of  risk  mixed  with  it,  goes  almost  without  saying.  It  is 
the  conviction  of  the  writer  that,  especially  in  the  case  of  girls,  such  talks  do 
far  more  good  when  given  to  the  girls  individually  rather  than  in  large 
groups,  as  is  so  often  the  case.  He  also  feels  that  in  addition  to  giving 
"  sex  hygiene  "  talks  to  young  girls  directly,  much  good  can  often  be  accom- 
plished by  instructing  the  mothers  regarding  the  advisability  of  enlighten- 

108 


THE  HYGIENE  OF  PUBERTY  109 

ing  their  own  daughters.  Tliere  is  scarcely  anything-  in  which  human  beings 
differ  so  much  as  in  their  attitude  toward  the  big  problem  of  sex,  and  hence 
the  cardinal  note  in  sex  instruction  should  be  individualization  —  the  adai> 
tation  of  the  matter  and  method  of  instruction  to  the  individual  case.  Such 
delicate  instruction  should  not  be  handed  out  indiscriminately. 

School  Life. —  Next  to  the  influence  of  the  home  itself,  the  most 
potent  factor  in  moulding  the  character  and  health  of  the  girl  at  the  time  of 
puberty  is,  in  the  majority  of  cases,  the  influence  of  school  life.  There  can 
be  no  question  that  the  tendency  of  recent  years  has  been  to  crowd  too  much 
into  the  curriculum  of  the  school  child.  This  seems  to  be  especially  true 
of  the  public  school  systems  of  most  of  the  large  cities  of  the  country, 
although  even  the  private  schools  are  not  blameless  in  this  respect.  This  is 
still  true,  notwithstanding  the  great  advances  made  in  this  respect  in  recent 
years  by  many  educational  institutions,  for  the  physical  betterment  of  their 
pupil  bodies.  It  would  seem  as  if  the  acquirement  of  much  knowledge, 
often  in  the  nature  of  mere  "  book  learning,"  has  been  the  sole  ambition  of 
modern  life.  Laudable  as  such  an  ambition  may  be,  it  may  be  pushed  to 
such  a  limit  as  to  be  unnatural  and  unwise.  These  terms  are  justified  when 
we  consider  that  the  educational  wave  has  left  in  its  train  thousands  of 
young  girls  —  we  are  discussing  more  especially  the  "  feminine  "  aspect  of 
the  problem  —  who  are  broken  in  health,  neurasthenic,  and  anemic. 

Such  serious  inroads  upon  the  health  of  the  young  girl,  coming  just  at 
this  crucial  period,  leave  a  lasting  impression  upon  her  body,  mind,  and 
soul,  and  many  an  invalid  woman  is  the  end  product  of  the  delicate,  over- 
worked schoolgirl.  The  more  ambitious  and  conscientious  the  girl,  the 
greater  her  application  to  her  studies,  and  the  greater  the  liability  to  injuri- 
ous effects  upon  her  health.  What  has  been  said  in  this  connection  applies 
especially  to  the  unreasonably  great  amount  of  home  work  which  is  assigned 
to  girls  in  many  schools.  After  spending  many  hours  in  class  rooms,  pupils 
are  obliged  to  devote  a  great  many  more  to  these  home  studies,  leaving 
very  little  time  for  the  conscientious  student  to  devote  to  purposes  of  recrea- 
tion. And  all  this  at  a  time  of  life  when  the  girl  is  especially  in  need  of 
relaxation,  and  when  lack  of  it  is  most  apt  to  leave  a  lasting  impress  upon 
her. 

Working  Conditions. —  In  the  class  of  girls  who  are  obliged  to  work 
for  a  living  at  a  very  early  age,  equally  injurious  effects  upon  the  general 
health  may  be  produced  by  occupations  which  deprive  the  girl  of  adequate 
rest  and  recreation.  This  evil  is  in  a  measure  mitigated  by  the  fact  that 
many  states  now  have  laws  regulating  the  age  at  which  a  child  may  be  sent 
to  work,  and  also  the  maximum  number  of  hours  during  which  she  may 
work.  In  spite  of  this  fact,  however,  there  are  still  thousands  of  girls  who 
are  compelled  to  perform  work  distinctly  injurious  to  them  at  or  about  the 
age  of  puberty,  when  they  are  most  in  need  of  fresh  air  and  recreation. 
Long  hours  of  standing  in  department  stores,  or  sitting  at  a  table  making 
cigars,  or  sewing  in  poorly  lighted  and  ill  ventilated  tailoring  shops — any 


110  MENSTRUATION  AND  ITS  DISORDERS 

one  of  these,  as  well  as  a  long  array  of  other  similar  occupations,  lay  the 
foundation  of  future  ill  health  and  perhaps  invalidism  in  thousands  of  cases. 
In  the  individual  case  it  is  the  duty  of  the  physician  to  point  out  the  dangers 
of  such  occupations  as  these  to  young  girls,  and,  in  so  far  as  it  may  be 
possible,  to  give  counsel  as  to  an  amelioration  of  the  injurious  conditions. 
On  the  other  hand,  it  is  equally  the  duty  of  communities  to  make  such 
things  impossible  by  the  enactment  and  enforcement  of  wise  laws  governing 
the  employment  of  children. 

Recreation  and  Rest. —  Just  what  form  of  recreation  or  exercise  is 
best  suited  for  the  girl  in  this  growing  stage  will  of  course  depend  in  great 
measure  upon  the  individual  case.  Exercise  in  the  open  air  is  unquestion- 
ably a  necessity  for  the  fullest  health  at  this  period  of  life.  Walking,  though 
not  so  popular  as  formerly,  is  one  of  the  very  best  forms  of  outdoor  exer- 
cise, and  should  be  encouraged  among  young  girls.  Any  of  the  numerous 
games  so  popular  among  boys  and  girls  are  also  of  value  in  this  respect,  for, 
in  addition  to  the  purely  physical  advantage  of  the  outdoor  exercise,  the 
spirit  of  the  game  increases  the  recreational  advantages.  The  same  state- 
ment applies  to  any  of  the  ordinary  forms  of  outdoor  sport  —  tennis,  row- 
ing, swimming,  croquet,  riding,  etc.  Needless  to  say,  even  these  may  be 
abused  when  carried  to  an  immoderate  degree.  Calisthenics  and  gym- 
nastics may  be  indulged  in,  either  indoors  or  in  the  open  air,  although  the 
latter  is,  of  course,  the  preferable  way. 

Dancing  has  always  been  a  popular  form  of  diversion  among  young 
girls,  and  there  is  no  doubt  that  the  graceful  stepping  and  balancing  which 
it  entails  are  of  distinct  physical  advantage.  On  the  other  hand,  it  can  not 
be  denied  that  distinct  harm  results  from  dancing  when  practiced  in  the 
intemperate  manner  so  frequently  seen.  The  exhilaration  of  the  dance  has 
a  great  tendency  to  make  the  dancer  forget  her  fatigue,  and  like  over- 
exercise  of  other  kinds,  the  harm  of  such  dancing  more  than  counterbalances 
any  good  that  may  come  of  it.  From  a  purely  moral  standpoint,  of  course, 
there  are  serious  objections  to  many  of  the  dance  halls  seen  in  most  of  our 
large  cities,  and  it  is  gratifying  to  know  that  many  of  our  municipalities  have 
already  taken  steps  toward  the  establishment  of  municipal  dance  halls, 
conducted  along  proper  lines.  This  advance  is  especially  important  from 
the  standpoint  of  the  working  girl,  whose  long  hours  of  monotonous  work 
make  her  eager  to  find  some  rather  exciting  and  perhaps  violent  form  of 
pleasure  and  diversion,  often  at  the  expense  of  the  sleep  which  is  so  essential 
to  her  health.  From  eight  to  ten  hours  sleep  should  be  obtained  by  the 
average  girl  in  the  growing  period  of  life. 

Clothing. —  With  regard  to  v^hat  might  be  called  personal  hygiene, 
it  need  only  be  said  that  this  is  largely  a  matter  of  common  sense.  Unfor- 
tunately, in  some  matters  common  sense  is  antagonised  by  Dame  Fashion, 
and,  with  perhaps  the  majority  of  young  girls,  the  latter  is  apt  to  come  off 
victorious.  In  this  connection,  the  incongruities  of  the  feminine  apparel  of 
the  present  day  at  once  suggest  themselves.     The  fashion  of  the  narrow  skirt 


THE  HYGIENE  OF  PUBERTY  111 

has  unfortunately  returned,  for  a  time  at  least.  Aside  from  its  incon- 
venience to  the  wearer  it  is  iniquitous  from  a  hygienic  standpoint,  for  it  is 
incompatible  with  naturalness  of  gait,  and  taids  to  produce  an  incorrect 
attitude  of  body.  Society  still  demands  that  the  dictates  of  common  sense 
be  set  aside  in  dressing  for  receptions,  balls,  the  theater,  and  other  such 
places  of  amusement,  and  that  decollete  gowns,  thin  stockings,  and  light 
slippers  be  worn  instead  of  those  of  heavier  and  warmer  character.  It  is 
not  surprising,  therefore,  that  such  functions  are  frequently  followed  by 
colds,  sore  throats,  and  perhaps  even  worse  sequelae,  often  seriously  under- 
mining the  health  of  the  girl. 

The  same  may  be  said  of  the  rather  prevalent  fad  among  girls  of  w^earing 
as  little  underclothing  as  possible,  and  of  wearing  the  same  light  summer 
undergarments  all  the  year  round.  This  is  done  with  the  idea  of  "  tough- 
ening "  themselves,  so  to  speak,  and  thus  rendering  themselves  less  vulner- 
able to  colds.  While  there  are,  no  doubt,  many  girls  who  may  do  this 
successfully,  the  frequent  and  oftimes  great  changes  in  our  climate  make  it 
risky  for  perhaps  the  majority  of  girls.  For  these,  it  is  no  doubt  safer  to 
don  heavier  underclothing  with  the  advent  of  the  cold  weather,  and  to  change 
the  upper  apparel  accordingly.  While  no  general  rule  can  be  laid  down 
for  all  girls,  it  may  be  said  that  the  body  should  be  sufficiently  warmly  clad 
to  prevent  any  chilling  of  the  surface. 

Bathing. —  It  is  scarcely  necessary  to  more  than  mention  the  im- 
portance of  personal  cleanliness.  Aside  from  its  cleansing  function,  the 
daily  bath  produces  a  feeling  of  exhilaration  and  well  being  which  is  in 
itself  a  sufficient  reward  for  taking  it.  The  bath  should  preferably  be  taken 
in  the  morning,  though  as  a  matter  of  convenience  many  take  it  later  in  the 
day.  If  the  bath  be  not  taken  every  day,  certainly  it  is  more  or  less  essen- 
tial to  bathe  at  least  twice  a  week,  especially  in  warmer  weather.  A  strong, 
robust  girl  will  enjoy  a  daily  cold  bath,  but  perhaps  the  majority  of  girls, 
especially  those  who  are  at  all  delicate  or  anemic,  prefer  it  more  or  less 
warm,  especially  in  cold  weather.  The  bathroom  should  always  be  com- 
fortably warm,  and  the  bath  should  be  followed  by  brisk  rubbing  with  a 
rough  towel,  so  as  to  provoke  a  healthy  reaction.  Cold  baths  should  not, 
generally  speaking,  be  taken  during  the  menstrual  period,  or  just  before  the 
flow  is  expected,  for  fear  of  bringing  about  a  suppression  of  the  function. 
Even  at  this  time,  however,  a  warm  bath  may  be  taken  with  comparative 
impunity,  although  most  girls  and  women  rely  upon  a  daily  sponge  bath 
instead.  Here  again  the  personal  equation  comes  into  play.  For  example, 
there  are  some  girls  who  take  a  cold  plunge  every  morning,  and  who  suffer 
no  ill  effects  even  when  this  is  kept  up  during  the  menstrual  periods. 

Diet. —  The  frequency  of  digestive  disturbances  among  young  women 
makes  it  advisable  to  call  attention  to  the  faulty  habits  of  diet  so  commonly 
seen  among  them.  The  strong,  healthy  girl  is  just  as  apt  to  have  a  good 
appetite  as  her  strong,  healthy  brother.  When  it  is  poor  and  capricious, 
therefore,  it  is  frequently  due  to  the  fact  that  instead  of  making  her  meals 


112  MENSTRUATION  AND  ITS  DISORDERS 

of  plain,  substantial  food,  the  g-irl  has  been  indulging  too  strongly  in 
"  dainties  ",  such  as  candies  and  pastries  of  various  sorts.  In  other  cases  — 
and  these  are  becoming  increasingly  numerous  —  the  poor  appetite  or  the 
stomach  disturbance  is  due  to  excessive  drinking  of  coffee  or  tea,  the  use  of 
both  having  been  increased  to  such  an  extent  that  they  are  now  looked  upon 
as  necessities  of  life.  If  used  by  the  growing  girl  at  all,  it  should  be  only 
sparingly.  The  drinking  of  milk  and  considerable  quantities  of  water  is 
much  more  beneficial. 

Care  of  the  Bowels. —  Attention  should  be  called  also  to  the  impor- 
tance of  a  proper  care  of  the  bowels,  for  the  constipation  so  often  seen  in 
young  girls,  and  which  so  often  persists  throughout  subsequent  life,  is  in  not 
a  few  cases  due  to  carelessness  and  neglect.  Both  in  the  case  of  school- 
girls and  of  working  girls  defecation  is  often  postponed  for  one  reason  or 
another,  until  finally  a  habitual  constipation  is  the  result.  This  is  a  matter 
of  considerable  importance,  and  girls  should  be  strongly  advised  to  heed  the 
calls  of  nature  with  as  little  delay  as  possible.  In  this  way  it  may  be  pos- 
sible to  avoid  a  condition  of  chronic  constipation  which  is  apt  to  be  more 
or  less  intractable  once  it  has  developed. 

Other  Hygienic  Measures  of  Importance. —  As  at  other  periods  of 
life,  the  proper  care  of  the  eyes,  the  ears,  the  nose,  the  throat,  and  the  teeth 
is  of  the  greatest  importance.  It  is  necessary  merely  to  allude  here  to  these 
hygienic  measures,  for  their  detailed  consideration  is  scarcely  within  the 
scope  of  such  a  work  as  this.  The  importance  of  such  measures  of  personal 
hygiene  to  the  developing  girl  can,  however,  scarcely  be  overestimated. 
The  habits  of  life  formed  by  the  girl  at  this  susceptible  and  flexible  period 
of  life  are  likely  to  persist  in  later  years,  and  hence  may  exert  a  vital 
influence  upon  the  entire  course  of  her  physical  life. 

X 

LITERATURE 

Christopher.     Nature  and  Management  of  Puberty.     Am.  Gyn.  and  Obst.  J., 

1898,  5,  321. 
Galbraith.     Personal  Hygiene  and  Physical  Training  for  Women.     Phila., 

1911. 
GoFFE.     Physical,  Mental,  and  Social  Hygiene  of  the  Growing  Girl.     Amer.  J. 

Obst.,  1911,  64,  213. 
Kelly.     Medical  Gynecology.     New  York,  1908, 
Ketcham.     The  Hygiene  of  Menstruation.     J.  Indiana  Med.  Assn.,  191 1,  4, 

224. 
KiscH.     The  Sexual  Life  of  Women  in  its  Physiological,  Pathological  and 

Hygienic  Aspects.     Translation  by  M.  E.  Patjl,  1910. 
MacEvitt.     Hygiene  of  Growing  Girls.     Am.  Med.,  191 1,  17,  435. 
WiLLE.     Die  Psychosen  des  Pubertatsalters.     Leipsig,  1898. 
Young.     The  Hygiene  of  Menstruation.     Intern.  Clin.  (Phila.)   1910,  i,  145. 


CHAPTER  XI 

PRECOCIOUS  MENSTRUATION 

What  Constitutes  Precocious  Menstruation?  —  Although  the  aver- 
age age  at  which  menstruation  begins  in  this  country  is  about  13.9  years, 
there  are  many  cases  in  which  the  age  of  onset  is  considerably  lower  than 
this.  As  a  matter  of  fact,  menstruation  may  occur  in  very  young  children, 
and  even  in  newly  born  infants.  Unless  the  variation  from  the  usual  age  of 
onset  is  very  great,  the  case  may  be  looked  upon  as  representing  merely 
an  individual  but  not  pathological  peculiarity.  If  the  variation  is  extreme, 
however,  as  in  the  case  of  newborn  infants,  the  case  must  be  considered 
one  of  pathologically  precocious  menstruation.  It  is  difficult  to  fix  an  arbi- 
trary dividing  line  between  normal  and  precocious  menstruation,  inasmuch 
as  there  are  many  individual  factors  to  be  considered.  Speaking  generally, 
however,  it  may  be  said  that  if  menstruation  begins  and  recurs  regularly 
in  a  girl  of  less  than  9  years  of  age,  in  this  climate,  it  must  be  looked  upon 
as  precocious.  Lenz  sets  the  age  before  which  menstruation  is  to  be  con- 
sidered precocious  as  8.  A  considerable  proportion  of  girls  commence  to 
menstruate  between  the  ages  of  8  or  9  and  14.  These  cases  may  be  looked 
upon  merely  as  cases  of  unusually  early  menstruation.  According  tO'  some 
recent  German  statistics,  menstruation  occurs  between  the  ages  of  8  and  12 
in  3.5  per  cent  of  all  cases  (Mayer  and  Kriger),  2.9  per  cent  (Schlicting), 
5.7  per  cent  (Schaffer),  2.."]  per  cent  (Grusdeff). 

Early  Manifestations  of  Premature  Development. —  The  history  of 
these  cases  of  precocious  menstruation  shows  that  some  evidence  of  preco- 
cious maturity  is  very  often  observed  at  the  birth  of  the  child.  In  some 
cases  it  is  the  unusually  large  size  of  the  child,  in  others  the  prominence 
of  the  breasts,  or  the  presence  of  hair  on  the  vulva. 

In  view  of  the  fact  that  body  growth  ceases  a  comparatively  short  time 
after  puberty,  the  precocious  onset  of  the  latter  would  seem  to  be  capable 
of  exerting  a  marked  influence  on  the  extent  of  the  skeletal  growth,  by 
bringing  about  early  ossification  of  the  epiphyseal  cartilages.  This  has  been 
emphasized  by  Tandler.  Gushing,  in  referring  to  the  studies  of  the  latter, 
says  "  that  the  normal  individual  in  whom  adolescence  occurs  at  an  early 
age  remains,  as  a  rule,  short  limbed,  whereas  those  with  a  tardy  adolescence 
are  long  limbed.  In  other  words,  early  sexual  development  indicates  early 
closure  of  the  epiphysis;  delayed  puberty  (of  which  artificial  eunuchism 
represents  the  extreme  example)  suggests  delayed  epiphyseal  union." 

Frequency. —  As  to  the  frequency  of  precocious  menstruation,  it  is 

113 


114 


MENSTRUATION  AND  ITS  DISORDERS 


difficult  to  arrive  at  any  accurate  opinion,  because  of  the  fact  that  many 
cases  are  not  reported.  Owing  to  the  increasing  interest  in  the  study  of 
the  physiology  and  pathology  of  menstruation,  many  more  are  now  finding 
their  way  into  the  literature  than  in  former  years.  Up  to  1800  only  18 
cases  had  been  recorded.  By  1900  the  number  had  increased  to  107.  The 
most  complete  recent  report  on  the  subject  is  that  of  Lenz,  Avho  has  studied 
the  records  of  130  cases  which  have  been  reported  from  1680  up  to  19 13. 
Since  then  a  number  of  additional  cases  have  been  reported  by  Gengenbach, 
Beekman,  and  others,  sending  the  total  up  to  one  hundred  and  fifty-one 
cases. 

Age  at  Which  Precocious  Menstruation  May  Be  Observed. —  As  to 
the  time  at  w^hich  the  onset  of  menstruation  is  noted  in  these  cases,  there  is 
a  wude  variation,  as  may  be  seen  from  the  subjoined  table  of  Lenz.  In  the 
130  cases  which  he  collected,  menstruation  was  observed  as  follows: 

At  the  time  of  birth 

Immediately  after  birth 

2  days  after  birth 

14  days  after  birth 

15  "         "         "     

2  months   "         "     


3 

4 

5 

6 

7 

8 

9 

10 

I 

year 

H 

years 

I* 

I* 

2 

2i 

2i 

2| 

3 

3i 

3i 

4 

5 

04 

6 

6i 

7 

Exact  time  unknown. 


m  I 

case 

"   2 

cases 

"   I 

case 

"   I 

(t 

"   I 

" 

"   I 

(k 

"   3 

cases 

"  4 

<( 

2 

it 

"  3 

(t 

"  3 

n 

"   I 

case 

"   Q 

cases 

"   2 

<( 

"  9 

ti 

"   I 

case 

"  II 

cases 

"   I 

case 

"  10 

cases 

"   I 

case 

"   I 

(t 

"   I 

" 

"  14 

cases 

"   I 

case 

"  2 

cases 

"  13 

(( 

"  6 

(t 

"   I 

case 

"  5 

cases 

"  2 

•( 

"  2 

(( 

"  14 

(< 

Total 130  cases 


PRECOCIOUS  MENSTRUATION  115 

Lenz  calls  attention  to  the  curious  fact  that  the  beginning  of  menstruation 
occurs  most  frequently  at  some  period  which  is  a  multiple  of  9  months. 
For  example,  at  the  age  of  9  months  9  cases  occurred;  at  the  age  of  1I/2 
years  (2x9  months),  11  cases;  3  years  (4x9  months),  14  cases;  6  years 
(8x9  months),  5  cases.  He  believes  that  if  the  age  at  which  the  flow 
appeared  in  these  cases  had  been  more  accurately  studied,  it  would  be  seen 
that  this  interesting  rule  would  be  even  more  apparent.  In  view  of  the 
fact  that  9  months  is  the  length  of  pregnancy  in  women,  and  that  menstrua- 
tion is  ordinarily  absent  during  pregnancy,  he  suggests  that  the  above 
observation  points  to  a  congenital  origin  of  the  tendency  to  precocious 
menstruation. 

Types  of  Precocious  Menstruation. —  According  to  Lenz,  there  are 
three  types  of  precocious  menstruation.  In  one  group  of  cases  the  premature 
onset  of  menstruation  is  accompanied  by  maturation  of  the  sexual  organs, 
and  is  associated  with  the  evidences  of  general  bodily  development  which 
ordinarily  characterize  puberty  —  the  rounding  of  the  figure,  the  growth 
of  pubic  and  axillary  hair,  etc.  This  group  embraces  the  majority  of  cases 
of  precocious  menstruation.  In  the  second  variety  of 'the  phenomenon,  the 
precocious  menstruation  and  the  development  of  the  reproductive  organs 
again  are  observed,  but  in  connection  with  tumors  involving  the  suprarenal, 
pituitary  body,  or  other  ductless  glands.  In  the  third  group,  seen  only  in  a 
small  minority  of  instances,  the  precocious  menstruation  occurs  in  the  entire 
absence  oi  any  other  manifestation  of  premature  activity  on  the  part  of  the 
generative  organs. 

As  will  be  gathered  from  what  has  been  said,  precocious  menstruation  is 
only  one,  though  perhaps  the  most  important,  of  the  symptoms  of  precocious 
development  of  the  entire  reproductive  apparatus,  and  this  in  turn  is  usually 
O'nly  one  manifestation  of  precocious  development  of  the  body  generally. 
As  contrasted  with  precocious  menstruation  (menstruatio  praecox),  some 
authors  speak  also  of  pubertas  praecox  and  evolutio  praecox.  It  may  be 
well  to  distinguish  between  these  three  terrhs.  By  "  menstruatio  praecox  " 
is  meant  the  discharge  of  blood  at  regular  periods  from  the  generative  tract 
of  girls  below  the  age  of  nine.  "  Pubertas  praecox  "  is  the  term  employed 
to  indicate  the  complex  of  anatomical  and  physiological  changes  in  the 
external  and  internal  generative  organs  of  girls  below  the  age  of  nine,  char- 
acterized by  certain  changes  in  the  breasts,  the  distribution  of  hair,  etc., 
together  with  the  appearance  of  certain  periodic  processes  of  which  men- 
struation is  the  most  important.  Finally,  by  "  evolutio  praecox  corporis," 
Lenz  has  reference  to  the  array  of  symptoms  associated  with  an  accelerated 
development  of  the  reproductive  system,  together  with  a  premature  stimula- 
tion of  bodily  growth.  The  latter  shows  itself  in  an  increase  in  the  size  as 
well  as  weight  of  the  body,  an  accelerated  growth  of  the  entire  skeleton,  and 
a  premature  ossification  of  the  epiphyseal  cartilages  —  all  these  symptoms 
occurring  in  girls-  below  the  age  of  nine. 

Clinical  Manifestations. —  The  two  most  common  symptoms  of  pre- 


116 


MENSTRUATION  AND  ITS  DISORDERS 


mature  development  in  female  children  are  precocious  menstruation  and 
mammary  h}Tpertrophy,  often  with  the  appearance  of  milk  in  the  breasts 
(Fig.  25).  We  have  already  spoken  of  the  age  at  which  precocious  men- 
struation may  appear.  The  amount  of  blood  lost  at  the  menstrual  periods 
in  these  cases  is  ordinarily  not  very  large,  to  judge  from  the  cases  in  which 
mention  is  made  of  this  feature.  In  Morand's  case  the  flow  lasted  always 
for  three  days.  In  Wetzler's  case  the 
duration  was  five  or  six  days,  Le  Beau's 
three  days,  Susewind's  two  days,  Loriot's 
three  days,  etc.  In  other  words,  the  dura- 
tion of  the  menstrual  flow  in  these  cases 
seems  to  vary  from  two  to  five  or  six 
days,  much  like  the  variations  in  the  dura- 
tion of  menstruation  in  normal  women. 

In  a  few  of  the  cases  which  occurred  in 
somewhat  older  girls,  the  patients  com- 
plained of  symptoms  similar  to  those  ex- 
perienced by  adult  women  at  the  time  of 
menstruation.  Thus  in  the  case  of 
Caesarano,  that  of  a  girl  of  seven  who  had 
commenced  to  menstruate  at  the  age  of 
six  months,  there  was  a  complaint  of  back- 
ache with  each  menstrual  period.  In 
Korsakov's  case,  while  the  age  of  the  girl 
is  not  given,  it  is  remarked  that  she  fre- 
quently suffered  with  hysterical  convul- 
sions at  the  menstrual  periods.  A  similar 
hysterical  tendency  was  noted  in  the  case 
recently  reported  by  Lenz.  Again,  in  the 
case  of  Plyette,  that  of  a  girl  of  four, 
mention  is  made  of  the  fact  that  the  pa 
tient  suffered  with  a  vicarious  flow  from 
the  nose. 

Subsequent  History  of  Patients  with 
Precocious  Menstruation. —  It  must  not 
be  assumed  that  in  all  of  these  cases  men- 
struation continues  uninterruptedly  up  to  Fig.  25. 
the  time  of  the  menopause.  Such  a 
course,  as  a  matter  of  fact,  seems  to  be 
the  exception  rather  than  the  rule.  In 
some    cases    menstruation     is 


-  Precocious  Development 
IN  A  Girl  of  Six. 


The  size  and  general  appearance  are 
those   of  a  child  of  at  least  thirteen 
years.    Menstruation  had  been  regular 
irreo"ular    ^ii^ce    the    age    of    six    months,    the 
'^  periods  lasting  3  or  4  days.    Note  the 

throughout,    as   in   those   of    Cooke,    Kor-    development  of  the  breasts  (Lenz), 

sakov,   and  Lenz.      In  other  cases   it   is 

regular  for  a  time  and  then  ceases  altogether.     In  Klein's  case  the  periods 

occurred  regularly  for  four  months,  were  followed  by  a  period  of  amenor- 


PRECOCIOUS  MENSTRUATION  117 

rhea,  and  ceased  altogether  following  an  attack  of  measles.  In  the  case 
of  Tulpiiis  menstruation  was  regular  from  the  age  of  four  to  the  age 
of  eight,  wdien  it  ceased,  being  followed  by  severe  attacks  of  head- 
ache. On  the  other  hand,  in  some  cases  menstruation  has  commenced  at  a 
very  early  period,  and  has  continued  without  interruption  —  except  when 
due  to  pregnancy  or  lactation  —  for  many  years.  Perhaps  the  most  notable 
example  of  this  is  the  well  known  case  of  Anna  Mummenthaler,  reported 
by  von  Haller  in  175 1.  This  patient  menstruated  regularly  from  the  age 
of  two.  At  nine  she  became  pregnant  and  gave  birth  to  a  child.  Menstrua- 
tion continued  regularly  up  to  the  age  of  fifty-two,  the  woman  reaching 
the  ag'e  of  seventy-five. 

Psychic  Development. —  In  spite  of  the  physical  precocity  in  these 
cases,  psychical  development  is  as  a  rule  very  poor.  In  the  case  reported 
by  Lenz  the  child  still  played  with  dolls  and  small  children  at  the  age  of 
ten.  Practically  all  authors  speak  of  the  childish  type  of  mind  in  these  cases. 
In  one  case  only,  that  of  Bouchut,  is  there  an  exception  to  this  rule,  the 
author  speaking  of  the  character  as  being  "  earnest  "  or  ''  serious."  Refer- 
ence has  already  been  made  to  the  case  of  Korsakov,  in  which  hysterical 
convulsions  occurred  at  the  time  of  the  menstrual  epochs.  Onanism  is 
mentioned  in  the  reports  of  three  cases,  those  of  Kornfeld  and  Nacke,  and 
that  of  Olinto,  the  latter  case  being  characterized  also  by  "  nervous  altera- 
tions." Lenz  speaks  of  the  legend  that  the  child  Mohamed  had  as  his 
concubine  the  eight  year  old  Kadisha,  although  Velpeau  believes  that  this 
is  based  upon  an  incorrect  translation  of  the  Koran. 

-Pregnancy  in  Cases  of  Precocious  Menstruation. —  To  show  the 
extent  to  which  sexual  maturation  may  advance  at  very  early  ages,  it  is 
interesting  to  note  that  quite  a  number  of  cases  of  pregnancy  have  been 
recorded  in  girls  who  exhibited  precocious  menstruation.  Perhaps  the  most 
remarkable  of  these  is  the  case  reported  by  Mandeslo,  of  a  child  who  com- 
menced to  menstruate  at  the  age  of  three,  and  who  gave  birth  to  a  son  at 
the  age  of  six.  In  addition  to  this  case  Lenz  has  collected  10  other  in- 
stances of  childbirth  at  ages  ranging  from  eight  to  twelve  years,  reported 
by  von  Haller,  Sue,  d'Outrepont,  Ramon  de  la  Sagra,  Montgomery,  Row- 
lett,  Carus,  Smith,  Molitor  and  Bodd. 

Cause  of  Precocious  Menstruation. —  In  the  majority  of  cases,  no 
definite  anatomical  explanation  can  be  found  for  the  occurrence  of  preco- 
cious menstruation  or  of  precocity  in  the  other  manifestations  of  puberty. 
In  view  of  our  ignorance  concerning  the  exact  cause  of  normal  puberty, 
we  can  only  say  that  premature  puberty,  like  the  normal  process,  is  probably 
due  to  a  stimulus  arising  in  some  way  from  the  ductless  gland  chain,  and 
especially,  of  course,  from  the  generative  glands. 

Much  weight  is  given  to  this  theory  by  the  autopsy  findings  in  a  number 
of  reported  cases.  Guthrie  and  Emery,  and  also  Hofacker,  have  reported 
cases  in  which  tumors  of  the  generative  glands  have  been  found  at  autopsy 
in  cases  of  precocious  puberty. 


118  MENSTRUATION  AND  ITS  DISORDERS 

Even  more  conclusive  are  several  cases  in  which  such  tumors  have  been 
removed  at  operation,  with  disappearance  of  the  signs  of  early  puberty. 
In  the  case  of  Lucas  the  signs  of  prematurity,  especially  the  prominent 
mammae,  disappeared  after  the  removal  of  a  sarcoma  of  the  ovary.  Brohl 
records  the  case  of  a  girl  of  seven,  with  precocious  menstruation  and  the 
development  of  a  mature  woman.  A  large  cystic  ovary  was  removed,  and, 
although  kept  under  observation  for  two  years  after  the  operation,  she  did 
not  menstruate  again.  A  similar  case,  occurring  in  a  childof  nine  years,  has 
been  reported  by  Sacchi.  The  most  recent  case  reported  is  that  of  Harris, 
whose  patient  was  five  years  of  age.  The  precocious  menstruation  in  this 
case,  as  well  as  other  manifestations  of  premature  development,  disap- 
peared completely  after  the  removal  of  a  carcinomatous  ovarian  teratoma 
of  the  right  ovary.  Numerous  cases  have  also  been  recorded  in  which 
tumors  of  other  ductless  glands,  notably  the  suprarenal,  pituitary,  pineal 
and  thyroid,  have  been  associated  with  symptoms  of  sexual  precocity. 
Bulloch  and  Sequeira,  as  well  as  other  authors,  have  described  such  cases. 
The  tumors  most  frequently  found  in  these  cases  are  hypernephromata. 

Neuman,  in  1901,  reported  22  cases  of  precocious  maturity  associated 
with  tumors  of  the  pineal  gland.  Very  few  autopsies  are  recorded  in  cases 
of  precocious  menstruation  in  which  there  was  no  tumor  present,  either  in 
the  ovaries  or  in  the  other  internal  secretory  glands.  Indeed,  I  have  been 
able  to  find  reference  to  only  one,  that  of  Prochownik.  This  patient  began 
to  menstruate  at  the  age  of  one  year,  flowing  every  four  weeks  for  two  or 
three  days,  up  to  her  death,  from  bronchitis,  at  the  age  of  three.  At  autopsy 
there  was  found  but  little  development  of  the  breasts,  which,  however,  con- 
tained gland  tissue.  Hair  was  present  in  the  axillae  and  about  the  external 
genitalia,  which  were  well  developed.  The  uterus,  both  from  the  stand- 
point of  its  size  and  of  the  proportion  between  the  cervix  and  body,  was  far 
beyond  the  normal  for  the  age  of  three.  The  endometrium  presented  the  ap- 
pearance usually  seen  in  the  adult  uterus  after  menstruation,  while  the 
ovaries  gave  indication  of  regular  ovulation. 

Diagnosis  of  Precocious  Menstruation. —  This  is  easy,  except  per- 
haps in  those  cases  which  develop  wSthin  the  first  few  days  after  birth. 
During  this  period  it  may  be  difficult  to  distinguish  the  condition  at 
once  from  the  simple  non-menstrual  hemorrhage  of  the  new  born  (see 
Chapter  XII). 

The  two  conditions  may  be  distinguished  by  the  fact  that  non-menstrual 
genital  hemorrhage  usually  occurs  at  about  the  fifth  or  sixth  day  after 
birth,  while  menstruation  does  not  as  a  rule  appear  until  later ;  that  genital 
hemorrhage  occurs  only  once,  while  menstruation  recurs  with  greater  or 
less  regularity;  and  that  genital  hemorrhage  is  not  associated  with  the  other 
signs  of  premature  development  which  are  so  frequently  present  with 
precocious  menstruation. 

The  only  other  condition,  from  which  it  is  necessary  to  differentiate  pre- 
cocious menstruation,  is  that  associated  with  the  precipitation  of  urates 


PRECOCIOUS  MENSTRUATION  110 

from  the  urine  of  infants,  often  giving  rise  to  the  presence  of  a  brick  red 
deposit  on  the  diapers.  On  casual  examination  this  might  be  mistaken  for 
blood.  If  there  is  any  doubt  concerning  the  real  character  of  such  stains, 
it  may  very  easily  be  cleared  up  by  microscopic  examination. 

JMention  should  also  be  made  of  the  value  of  the  X-ray,  both  for  diagnostic 
and  purely  scientific  purposes.  It  gives  the  best  evidence  of  somatic  devel- 
opment by  depicting  the  advanced  stage  of  skeletal  development  in  these 
cases  of  precocious  maturity.  This  has  been  emphasized  by  Lenz,  Neurath 
and  Wolf.  The  bones  are  larger  than  normal  for  the  age,  and  ossification 
is  farther  advanced  than  would  be  expected ;  the  epiphyses  often  being  fully 
joined  to  the  shafts,  or  else  being  separated  by  only  thin  discs  of  cartilage. 
Special  attention  is  called  to  the  pelves  of  such  children,  for  in  many  cases 
they  resemble  those  of  the  fully  matured  woman. 

Treatment  of  Precocious  Menstruation. —  Medicinal  treatment  is 
never  required  in  these  cases.  The  time  will  probably  come  when  organo- 
therapy will  be  of  prime  value  in  the  treatment  of  this,  as  well  as  other 
menstrual  disturbances.  At  present,  how'ever,  our  knowledge  of  this  sub- 
ject is  so  imperfect  that  no  intelligent  plan  along  these  lines  can  be 
suggested. 

As  Morse  emphasizes,  the  psychological  treatment  of  these  cases  of 
premature  development  is  of  much  importance.  The  frequent  early  develop- 
ment of  sexual  desire,  long  before  the  development  of  will  power,  exposes 
these  children  to  the  danger  of  violation,  as  is  shown  by  the  many  cases  of 
very  early  pregnancy  which  are  recorded.  Every  effort  should  therefore 
be  made,  along  individual  lines,  to  prevent  them  from  such  unfortunate 
accidents. 


XI 

LITERATURE 

Beekman.     Precocious  Maturity  in  Girls,  with  Report  of  Case.     Arch.  Pediat., 

1915,  z^,  4- 
BiEDL,     Innere  Sekretion.     1910. 
Brohl.     Ovarialkystome  in  /-jahriges  Madchen.     Zentralb.  f.  Gyn.,  1897,  21, 

113- 
Bulloch  and  Seoueira.     On  the  Relation  of  the  Supra-renal  Capsules  to  the 

Sexual  Organs.     Tr.  Path.  Soc.  of  Lend.,  1905,  56,  189. 
Groom.     Premature  Menstruation.     Allbutt's  Syst.  of  Gyn.,  1906. 
CusHiNG.     The  Pituitary  Body  and  its  Disorders.     Phila.,  1910. 
Falta.     Die  Erkrankungen  der  Blutdriisen.     191 3. 
FoTHERGiLL.     Note  on  Some  Developmental  Errors  of  Puberty.     Brit.  M.  J., 

1912,  2,  1120. 
Gengenbach.     Precocious  Menstruation.     Jour.  A.  M.  A.,  1913,  61,  563. 
Glynn.     The  Adrenal  Cortex;    its  Rests  and  Tumors,  etc.     Quart.  J.  Med., 

1911-12,5,157. 


120  MENSTRUATION  AND  ITS  DISORDERS 

Guthrie.  Extreme  Obesity  and  Precocious  Puberty.  Tr.  Clin.  Soc,  Lond., 
1906,  39,  252. 

AND  Emery.  Precocious  Obesity,  Premature  Sexual  and  Physical  Devel- 
opment, etc.     Tr.  Clin.  Soc.  Lond.,  1907,  40,  175. 

Halban.  Die  Fotale  Menstruation  und  ihre  Bedeutung.  Zentralb.  f.  Gyn., 
1904,  28,  1270. 

Harris.  Carcinomatous  Ovarian  Teratoma  with  Premature  Puberty  and  Pre- 
cocious Somatic  Development.     Surg.  Gyn.  and  Obst.,  1917,  24,  604. 

HoFACKER.  Ein  Seltener  Fall  von  Friihreife  mit  Menstruatio  Praecox.  Zen- 
tralb. f.  Gyn.,  1898,  22,  II 20. 

Jump,  Bates,  and  Babcock.  Precocious  Development  of  External  Genitals 
Due  to  Hypernephroma  of  Adrenal  Cortex.  Amer.  J.  Med.  Sc,  1914, 
147,  568. 

Klein.     Ein   Fall  von   Pubertas  Praecox.     Deutsch.   Med.   Wchnsch.,    1899, 

25.  47- 
Klemm.     Menstruatio  Praecox.     Inaug.  Diss.,  Coburg,  1902. 
Lenz.     Vorzeitige  Menstruation,  Geschlechtsreife,  und  Entwicklung.     Arch. 

f.  Gyn.,  191 3,  99,  67. 
Lucas.     Tumor  in  Right  Ovary  in  a  Child  Aged  Seven.  Years  Associated  with 

Precocious  Puberty;  Ovariotomy;  Cure.     Trans.  Clin.  Soc.  Lond.,  1888, 

21,  224. 
Mandeslo,  1658.     Quoted  by  Lenz. 
]\Iapes.     Precocious     Menstruation     and     Precocious    Pregnancy.     Memphis 

Lancet,  1898,  i,  289. 
McWalter.     Menstruation  in  an  Infant.     Brit.  M.  J.,  1907,  2,  1736. 
Meige.     Gigantisme  precoce  avec  puberte  precoce.     Revue  Neurolog.,   1903, 

II,  533- 
Morse.     Precocious  Maturity.     Arch,  of  Pediat.,  1897,  14,  241. 

Also  Arch  of  Pediat,  1913,  30,  179. 

Munzer.     Menstruatio    Praecox  und   Psychische   Entwicklung,     Berl.    Klin. 

Wchnsch.,  1914,  51,  448. 
Nacke.     Menstruatio  Praecox.     Zentralb.  f.  Gyn.,  1908,  32,  11 16. 
Neuman.     Zur  Kenntnis  der  Zirbeldriisengeschwiilste.     Monats.  f.  Psychiat., 

1901,  60,  337. 
Neurath.     Vorzeitige  Geschlechtsentwicklung  (Menstruatio  Praecox).   Wien. 

Med.  Wchnsch.,  1909,  59,  1301. 
Ploss.     Das  Weib  in  der  Natur  und  Volkerkunde.     2te  aufl.  Leipz.,  1887. 
Prochownik.     Ein  Fall  von  Menstruaitio  Praecox  mit  Sektionsbefund.     Arch. 

f.  Gyn.,  1881,  17,  330. 
Runge.     Beitrag  zur  Anatomic  der  Ovarien  Neugeborener  und  Kinder  vor  der 

Pubertatszeit.     Arch.  f.  Gyn.,  1906,  80,  43. 
Stein.     Ein    Typischer    Fall    von    Menstruatio    Praecox.      Deutsch.    Med. 

Wchnschr.,  1904,  30,  1275. 
St5ltzner.     Menstruatio  Praecox.     Med.  Klinik,  1908,  4,  5. 
WiNTERNiTZ  UND  FiNALY.     Ucber  Ovarialgcschwiilste  bei  Kindern.     Jahrb.  f. 

Kinderh.,  1905,  62,  402. 
Wolf.     Zur  Kenntnis  der  Entwicklungsanomalien  bei  Infantilismus  und  bei 

Vorzeitiger  Geschlechtsreife.     Zentralb.  f.  Gyn.,  191 1,  35,  i543- 
Woodruff.     Case  of  Unusually  Early  Menstruation.     Med.  Rec,  1896,  49,  338. 


CHAPTER  XII 
NON-MENSTRUAL  GENITAL  HEMORRHAGE  IN  THE  NEW  BORN 

Differentiation  from  Precocious  Menstruation. —  It  is  probable  that 
many  cases  which  have  been  reported  in  the  hterature,  particularly  the 
earlier  literature,  as  cases  of  precocious  menstruation  were  in  reality  in- 
stances of  hemorrhage  of  non-menstrual  character.  It  has  been  known  for 
many  years  that  hemorrhage  not  infrequently  occurs  from  the  genitals  of 
new  born  female  infants  within  a  few  days  of  their  birth.  The  differences 
between  such  hemorrhages  and  those  indicative  of  early  appearance  of  the 
menstrual  function  have  already  been  mentioned  (see  chapter  on  "  Pre- 
cocious Menstruation").  Briefly,  the  main  points  of  differentiation  are  the 
appearance  of  non-menstrual  bleeding  usually  within  the  first  week  of  life, 
its  failure  to  recur  as  in  menstruation,  and  the  absence  of  other  secondary 
sexual  manifestations.  It  is  true  that,  in  exceptional  cases,  non-menstrual 
genital  hemorrhages  have  recurred  once  or  even  several  times,  as  in  Kerk- 
ring's  patient,  quoted  by  Halban.  Such  an  occurrence,  however,  is 
exceedingly  rare. 

Frequency. —  Among  10,000  new  born  female  infants  Shukowsky 
found  35  cases  of  genital  bleeding;  a  proportion  of  i  to  every  285.  Bilhard, 
by  an  actual  study  of  the  uteri  from  700  new  born  girls,  found  evidences  of 
uterine  bleeding  in  only  two  cases.  Lequeux  and  Marioton  put  the  pro- 
portion of  such  cases  at  0.61  per  cent,  Renouf  at  2.59  per  cent,  Zacharias 
at  2.5  per  cent,  and  von  Winckel  at  0.12  per  cent.  Halban,  from  a  histo- 
logical study  of  21  cases,  claimed  to  have  determined  the  existence  of 
genital  bleeding  in  eight,  giving  the  rather  startling  proportion  of  38.09  per 
cent.  In  a  similar  study  of  12  cases  Zacharias  found  bleeding  in  i,  or  8.3 
per  cent.  Single  cases  have  been  reported  by  a  number  of  American 
authors.  From  these  figures,  it  may  be  gathered  that  while  genital  hemor- 
rhage in  the  new  born  is,  comparatively  speaking,  a  rare  occurrence,  the 
frequency  of  its  recognition  would  be  no  doubt  much  increased  were  a 
careful  histological  study  made  of  the  vaginal  secretion  in  all  of  a  given 
series  of  cases. 

Time  of  Occurrence  of  Bleeding. —  In  the  majority  of  cases,  the 
bleeding  is  noted  on  about  the  sixth  or  seventh  day.  Shukowsky,  in  his 
large  series  of  cases,  had  never  observed  it  before  the  fifth  day.  On  the 
other  hand,  Purefoy,  Engstrom  and  Frew  have  observed  it  even  on  the  first 
day  of  life,  Bride  and  Carus  on  the  second,  von  Winckel  on  the  third,  and 
Pollak  and  Cullingworth  on  the  fourth.     Bednar  and  Ritter  found  it  to  be 

121 


122  MENSTRUATION  AND  ITS  DISORDERS 

most  common  on  the  fifth  day,  Zacharias,  in  lo  cases,  observed  the  bleed- 
ing on  the  fourth  day  in  3,  on  the  sixth  in  4,  and  on  the  seventh  in  the 
remaining-  3.  It  will  thus  be  seen  that,  while  genital  hemorrhage  may  occur 
on  any  one  of  the  first  seven  days  of  life,  it  is  much  more  frequent  on  the 
sixth  and  seventh  days  than  on  the  first  five. 

Duration  of  Bleeding. —  It  is  exceptional  for  the  bleeding  to  continue 
longer  than  a  day  or  two.  In  6  of  Zacharias'  cases,  it  continued  i  day,  in 
three  2  days,  and  in  one  3  days.  Jardine,  however,  speaks  of  a  case  in  which 
the  bleeding  lasted  4  days,  while  Busey  mentions  one  in  which  it  continued 
4^  days,  Pollak  one  of  5  days'  duration,  Bates  one  lasting  7  days,  and 
Engstrom  one  in  which  the  bleeding  was  present  for  8  days.  Such  long 
durations  as  these,  however,  are  quite  exceptional. 

Amount  and  Character  of  Bleeding. —  The  bleeding  in  these  cases  is 
practically  never  severe,  and  usually,  as  a  matter  of  fact,  is  drop-like  in 
character.  Often  it  is  so  slight  as  scarcely  to  be  noticeable,  although  Busey 
and  Jardine  have  reported  cases  in  which  the  hemorrhage  was  quite  profuse. 
According  to  Gebhard,  as  much  as  30  gms,  of  blood  has  been  lost  with  this 
type  of  bleeding. 

In  many  cases  the  bleeding  is  introduced  by  an  increased  secretion  of 
mucus.  The  clear  appearance  of  the  latter  then  gives  way  to  a  bloody 
discoloration,  until  often  a  drop  of  blood,  or  perhaps  a  blood  clot  is  noticed 
on  or  between  the  labia.  In  other  cases  there  seems  to  be  no  preliminary 
mucous  discharge.  The  blood  is  bright  red  in  color,  later  becoming  dark 
brown  or  even  chocolate  colored.  Microscopically,  according  to  Jardine, 
the  blood  presents  no  pathological  alterations. 

Accompanying  Symptoms. —  Many  authors  attribute  significance  to 
various  clinical  symptoms  not  infrequently  associated  with  the  bleeding. 
For  example,  Shukowsky  believes  that  all  infants  who  exhibit  this  phe- 
nomenon suffer  from  intestinal  disturbances.  Others  lay  stress  on  a  septic 
factor,  while  Eross  observed  in  such  cases  an  acute  catarrh  of  the  mucosa 
covering  the  pars  vaginalis.  Frew,  in  his  case,  noted  that  convulsions  were 
associated  with  the  bleeding.  On  the  other  hand,  most  authors,  including 
Zacharias,  Juda  and  Engstrom,  speak  of  the  entire  absence  of  any 
associated  symptoms. 

Prognosis. —  Opinion  is  virtually  unanimous  among  writers  that  the 
prognosis  in  such  cases  is  favorable.  Only  Busey  is  inclined  to  believe 
that  it  is  not  unassociated  with  danger  to  weak  children. 

Etiology. —  Although  many  hypotheses  as  to  the  cause  of  genital 
hemorrhage  in  the  new  born  have  been  suggested  by  writers  on  this  subject, 
none  has  gained  general  approval  and  acceptance.  It  is  of  interest  to  review 
a  few  of  the  explanations  which  have  been  offered  for  the  phenomenon. 
Shukowsky,  finding  intestinal  disturbances  frequently  associated,  attributed 
an  etiological  role  to  them.  He  suggested  that,  by  inducing  a  general 
visceral  hyperemia,  they  predisposed  to  such  hemorrhages.  Von  Winckel 
gave  hemophiha  as  a  causative  factor  in  one  of  his  cases,  the  mother  being  a 


NON-MENSTRUAL  GENITAL  HEMORRHAGE  IN  THE  NEW  BORN      123 

sufferer  from  the  disease.  Ritter  looks  upon  the  bleeding  as  the  manifesta- 
tion of  an  existing  sepsis.  Doleris  believes  that  some  infection  of  unknown 
nature  caused  the  epidemic-like  appearance  of  genital  bleeding  in  five 
infants  in  an  obstetrical  ward  at  the  same  time,  four  of  them  dying.  Hen- 
nig  believed  that  congenital  cardiac  insufficiency  causes  some  cases  of  this 
type,  the  bleeding  being  only  an  indication  of  the  associated  passive  con- 
gestion. Asphyxia  of  the  new  born  babe  has  also  been  held  responsible. 
According  to  Henoch,  papillomata  of  the  vulva  or  vagina  may  cause  bleed- 
ing; as  may  also  sarcoma  of  the  ovary  (Gautier).  The  possibility  that 
genital  bleeding  may  be  caused  by  trauma  either  during  or  after  delivery, 
cannot  be  gainsaid.  Zacharias  lays  stress  on  the  fact  that  it  is  in  large 
babies  especially  that  such  hemorrhages  are  seen.  He  quotes  von  Winckel, 
and  also  Lequeux  and  Marioton,  as  emphasizing  this  fact,  and  finds  in  his 
own  series  of  lo  cases,  that  the  infants  weighed  from  3150  gm.  to  4840  gm., 
as  compared  with  the  average  of  3000  gm. 

The  theory  of  Halban  alone  is  based  upon  a  scientific  study  of  the  ques- 
tion. By  a  careful  macroscopic  and  microscopic  study  of  8  uteri  from  which 
more  or  less  hemorrhage  was  taking  place,  he  established  the  fact  that  the 
local  process  was  quite  similar  to  that  found  In  normal  menstruation,  thus 
confirming  the  earlier  observation  of  Zappert.  According  to  Halban,  the 
capillaries  of  the  mucosa  were  always  filled  with  blood,  as  well  as  the  sub- 
mucous and  periuterine  vessels.  Here  and  there  hemorrhages  were  seen 
extending  under  the  epithelium.  Defects  of  the  latter  were  not  seen,  except 
occasionally  a  flattening  due  to  the  pressure  of  the  escaping  blood. 

Halban  also  demonstrated  that  the  ovaries  in  such  cases  gave  no  evidence 
of  active  function,  and  he  therefore  sought  elsewhere  for  a  possible  cause 
of  the  menstrual  picture  In  the  uterus.  This  he  attributed  to  the  presence 
in  the  fetal  circulation  of  substances  formed  In  the  maternal  placenta,  wdiich 
thus  acts  as  an  organ  of  Internal  secretion.  The  placental  secretion  produces 
a  hypertrophy  of  the  fetal  uterus,  so  that,  as  a  matter  of  fact,  the  organ  Is 
larger  at  the  time  of  birth  than  It  Is  for  some  time  afterward.  Halban  essays 
to  prove  these  statements  by  the  dimensions  of  the  uterus  at  birth  and 
afterward,  as  given  by  various  authors.  He  himself  found  the  average 
length  of  the  uterus  in  11  new  born  Infants  to  be  3.2  cm.,  while  the  average 
for  Infants  who  died  at  ages  varying  from  three  weeks  to  two  years  was  2.5 
cm.  In  addition  to  the  Increase  In  the  size  of  the  uterus,  Halban  states  that 
the  placental  secretion  brings  about  a  hyperemia  of  the  uterus  which  may 
reach  a  grade  sufficient  to  cause  active  bleeding  after  delivery.  The  recent 
experiments  of  Schlckele,  Aschner,  and  Fellner  seem  to  substantiate  Hal- 
ban's  view  In  that  extracts  of  placenta  when  Injected  Into  the  circulation  are 
stated  to  cause  an  Increase  In  size  of  that  organ,  with  vasodilation  and  a 
tendency  toward  hemorrhage. 

Treatment. —  In  view  of  the  slight  amount  and  the  short  duration 
of  the  bleeding  In  practically  all  cases,  no  treatment  Is  necessary.  Various 
measures  have  been  recommended,  apparently  "  ut  allquld  fiat."       Thus, 


124  MENSTRUATION  AND  ITS  DISORDERS 

Busey  gave  in  his  2  cases  small  doses  of  the  fluid  extract  of  hydrastis 
canadensis.  Juda,  again,  has  made  use  of  a  10  per  cent  gelatin  solution  in 
dram  doses  several  times  a  day.  Biedert  advises  that  warm  baths  be  not 
given  during  the  bleeding.  It  is  doubtful,  however,  v^^hether  any  of  these 
measures  have  any  effect  on  the  bleeding,  which  tends  to  cease  spontaneously. 

XII 
LITERATURE 

Aschner.     Ueber  Brunstartlge  Erscheinungen  nach  Subacutaner  Injektion  von 

Ovarial-  oder  Placentarextrakt.     Arch.  f.  Gyn.,  191 3,  99,  534. 
Bates.     Early  Menstruation.     Brit.  M.  J.,  1902,  2,  976. 
BiEDL.     Innere  Sekretion,  1910. 
BusEY.     Blutige  Ausfluss  aus  der  Vulva  oder  Vagina  beim  Neugeborenen. 

Arch.  f.  Kinderheilk.,  1892,  19,  104. 
CuLLiNGWORTH.     Hemorrhage  from  the  Genital  Organs  in  the  Recently  Born 

Female  Child.     Manchester,  1876. 
Dewar.     Vaginal  Hemorrhage  and  Milky  Secretion  from  Mammae  in  Infant. 

Brit.  M.  J.,  1908,  I,  1423. 
Drake.     Vaginal  Hemorrhage  in  New-Born.     Jour.  A.  M.  A.,  1907,  49,  775. 
Engsrtom.     Genitalblutungen  bei  einem  Neugeborenen  Madchen.     Jahrb.  f. 

Kinderheilk.,  1894,  38,  500. 
Falta.     Die  Erkrankungen  der  Blutdriisen.     1913. 
Fellner.     Experimentelle  Untersuchungen  iiber  die  Wirkung  von  Gewebsex- 

tracten  aus  der  Placenta  und  den  Weiblichen  Sexualorganen.     Arch.  f. 

Gyn.,  1913,  100,  641. 
Frew.     Menstruation  in  a  Newly  Born  Female  Child  with  Convulsions.    Brit. 

M.  J.,  1902,  I,  1536. 
Halban.     Die    Fotale    Menstruation    und    ihre    Bedeutung.       Berl.     Klin. 

Wochensch.,  1904,  28,  1270. 
Jardine.     Menstruation  in  a  New-Born  Infant.     Brit.  M.  J.,  1897,  2,  652. 
Juda.     Ueber  Uterusblutungen  Neugeborenen     Med.  Klin.,  Berl.,  191 3,  9,  584. 
Lequeux  et  Marioton.     La  crise  genitale  chez  le  nouveau  vie,  etc.,  (quoted 

by  Zacharias). 
McWalter.     Menstruation  in  Infant.     Brit.  M.  J.,  1907,  2,  1736. 
PuREFOY  AND  Carton.     Menstruation  in  Infants.     Dublin  J.  of  Med.   Sci., 

1902,  113,  340. 
Sedlacek.     Metrorrhagia  in  the  Newborn.     Casop.  Lek.  Cesk.  v  Praze.,  1908, 

47,  1445- 
Shukowsky.     Blutungen  aus  den  Genitalorganen  bei  Neugeborener  Madchen. 

(quoted  by  Schaffer,  in  Veit's  Handbuch  d.  Gyn.). 
Zacharias.     Genitalblutungen    Neugeborener   Madchen.     Med.    Klin.,    Berl., 

1914,  10,  1645. 
Zamazal.     Metrorrhagia  in  the  Newborn.     Casap.  Lek.  Cesk.  v  Praze,  1908, 

47,  1445- 
Zappert.     Ueber  Genitalblutungen  bei  Neugeborener  Madchen.     Wien.  Med. 

Woch.,  1903,  53,  1477. 


CHAPTER  XIII 

THE  MENOPAUSE 

Definition. —  The  menopause  marks  the  termination  of  the  reproductive 
stage  of  a  woman's  Hfe,  the  most  prominent  dinical  manifestation  of  this 
transition  period  being  the  cessation  of  the  menstrual  flow.  The  menopause 
is  also  often  spoken  of  as  the  climacterium  or  climacteric,  while  among  the 
laity  it  is  most  frequently  called  the  "  change  of  life." 

Historical. —  Although  menstruation  itself  was  the  subject  of  much 
speculation  among  the  ancients,  as  we  have  already  seen  (Chapter  I),  much 
less  attention  seems  to  have  been  given  to  the  phenomenon  of  the  cessation 
of  the  menstrual  function.  By  the  old  school  of  humoral  pathologists,  the 
cessation  of  menstruation  was  looked  upon  as  a  matter  of  serious  conse- 
quence, often  causing  serious  disorders  and  calling  for  the  operation  of 
blood  letting.  Perhaps  these  old  observers  are  in  part  responsible  for  the 
great  dread  with  vdiich  the  menopause  is  even  now  looked  forward  to  by  a 
large  proportion  of  womankind. 

Currier  quotes  Hoffman,  one  of  these  humoral  pathologists,  as  saying 
that,  "  if  venesection  is  omitted  when  the  menses  cease,  violent  cardialgias 
will  result,  accompanied  with  intense  heat  and  pain  about  the  precordia, 
the  back,  and  scapulae,  especially  in  the  night  time.  Others  will  suffer  with 
intolerable  heat,  pain  in  the  joints,  and  erysipelatous  fevers,  while  still  others 
will  be  affected  with  nephritic  disorders  accompanied  with  pain  in  the  loins, 
and  terminating  in  calculous  concretions.  Furthermore,  some  women,  after 
their  sixtieth  year,  have  discharges  of  bloody  urine,  or  are  seized  with 
immoderate  discharge  of  their  menses,  which  at  last  terminates  in  an  hectic. 
Some  women,  especially  those  who  are  wasted  by  prolonged  grief,  have  been 
afflicted  with  pain  In  the  left  hypochondrlum  accompanied  with  uneasiness 
and  heat  in  the  precordia,  wihlch  afterwards  terminates  In  a  violent  vomiting 
of  the  blood  or  the  morbus  niger  of  Hippocrates.  In  such  patients,  upon 
opening  their  bodies,  the  spleen  has  been  found  preternaturally  large  and 
putrid,  the  vasa  brevia  of  the  stomach  ruptured  and  gaping,  and  the  blood 
discharging  from  these  vessels  Into  the  ileum."  In  this  description  It  Is  not 
difficult  to  recognize  the  "  Intolerable  heat "  as  the  distressing  vasomotor 
flushing  and  the  flashes  of  heat  from  which  the  climacteric  woman  Is  so 
wont  to  suffer,  while  the  "  Immoderate  discharge  of  their  menses  which  at 
last  terminates  in  an  hectic  "  clearly  has  reference  to  the  cancerous  disease 
which  Is  so  apt  to  occur  at  this  period. 

In  the  same  connection,  Hippocrates  states  :   "  We  learn  from  experience 

125 


126  MENSTRUATION  AND  ITS  DISORDERS 

that  exulcerations,  violent  and  even  scirrhous  tumors  of  the  uterus,  are 
sometimes  produced  by  cessation  of  the  menses.  Neither  do  the  external 
parts  of  the  body  escape  the  fatal  consequences  of  such  suppression,  since  we 
know  from  experience  that  by  this  means  they  are  frequently  affected  with 
the  itch,  the  elephantiasis,  boils,  erysipelatous  disorders,  or  scirrhous 
tumors."  Here  again,  we  have  an  unmistakable,  though  crude,  picture  of 
cancerous  disease.  The  middle  ages  brought  very  little  new  knowledge 
concerning  the  nature  of  the  climacterium,  and,  as  was  said  concerning  the 
study  of  menstruation  in  general,  it  is  during  the  past  fifteen  or  twenty 
years  that  most  of  our  new  knowledge  concerning  this  subject  has  been 
contributed. 

The  Age  at  Which  the  Menopause  Occurs. —  As  with  puberty,  the 
age  at  which  the  menopause  occurs  is  subject  to  wide  variation.  As  a 
general  rule,  in  this  climate,  menstruation  ceases  between  the  ages  of  40 
and  50,  and  in  my  experience,  more  frequently  between  the  ages  of  45  and 
50  than  between  40  and  45.  In  a  series  of  100  white  women  in  Baltimore, 
representing  various  nationalities,  I  found  that  58  ceased  tO'  menstruate 
between  45  and  50,  30  between  the  ages  of  40  and  45,  3  below  the  age  of 
40,  and  9  above  the  age  of  50.  The  extremes  noted  in  this  series  were  27 
years  and  54  years.  The  most  recent  statistical  study  of  this  question  is 
by  Sanes,  who  collected  the  literature  from  thirty-two  nations.  He  finds 
the  average  menopause  age  of  all  the  cases  to  be  47.1  years.  This  figure 
is  somewhat  higher  than  those  of  Currier,  who  in  a  series  of  96  women, 
found  that  30  stopped  menstruating  between  the  ages  of  45  and  50,  31 
between  the  ages  of  40  and  45,  27  below  the  age  of  40  and  8  above  the  age 
of  50.  The  extremes  were  30  and  53  years.  The  statistics  of  Kisch, 
based  on  the  study  of  500  German  women,  correspond  closely  to  my  own. 
In  455  cases  he  found  that  the  menopause  occurred  in  48  between  the  ages 
of  35  and  40,  in  141  between  the  ages  of  40  and  45,  in  177  between  the 
ages  of  45  and  50,  and  in  89  between  the  ages  of  50  and  55.  In  Berlin, 
Mayer  studied  1546  cases,  giving  an  average  of  47.04  years.  Among 
French  statistics  may  be  mentioned  those  of  Leudet,  who  found  the  average 
age  of  the  menopause  for  women  in  easy  circumstances  to  be  47.4  years ; 
for  those  obliged  to  work  hard  for  a  living  48.7  years;  and  for  those  who 
lived  in  the  country  47.9  years. 

The  histories  of  1082  English  and  French  women,  analyzed  by  Tilt, 
showed  the  average  age  of  the  menopause  to  be  45.7  years.  According  to 
Borner,  the  average  for  the  women  of  northern  Europe  is  higher  than  that  1 
for  the  women  of  southern  Europe.  Other  statistics,  quoted  by  Currier, 
are  those  of  Rodsewiitch,  who  gave  the  average  for  St.  Petersburg  women  as 
48.7  years ;  Binsenger,  who  at  Moscow  found  it  to  be  between  40  and  43 ; 
and  Hanover,  who  found  the  average  age  of  312  cases  studied  in  Denmark 
to  be  44.82  years. 

Finally,  from  an  investigation  conducted  by  Currier  upon  the  menstrual 
function  in  native  American  women,  it  appears  that  in  the  Sac  and  Fox 


THE  MENOPAUSE  127 

tribes,  menstruation  ceases  at  about  the  age  of  48 ;  in  the  Crow  and  Assini- 
boine  at  49  or  50;  in  the  Uintah,  between  40  and  50;  in  the  Apache, 
between  42  and  53,  while  in  the  Cheyenne  and  Arapahoe  the  extremes  were 
46  and  yi,  and  in  the  Sioux  38  and  58  years. 

From  a  study  of  these  various  reports,  it  would  appear  that  Webster  is 
correct  when  he  says,  concerning  the  age  at  which  the  menopause  occurs, 
that  "  in  temperate  countries  it  takes  place  in  about  fifty  per  cent  of  women 
between  forty-five  and  fifty;  in  twenty-five  per  cent,  between  forty  and 
forty-five;  in  twelve  and  one-half  per  cent,  between  thirty-five  and  forty; 
and  in  twelve  and  one-half  per  cent,  fifty  and  fifty-five."  From  what  has 
been  said  as  to  the  age  of  onset  of  the  menstrual  function  (Chapter  IX) 
it  will  be  seen  that  the  average  duration  of  the  menstrual  life  of  woman  is 
about  32  years. 

Factors  Influencing  the  Age  of  the  Menopause. —  Speaking  gener- 
ally, it  seems  to  be  true  that  the  earlier  the  menstrual  function  is  established 
the  longer  it  will  continue.  In  other  words,  if  puberty  occurs  at  an  early 
age,  the  menopause  is  apt  to  be  late  in  its  appearance,  the  reverse  being  true 
also.  This  is  contrary  to  the  view  commonly  held  by  the  laity.  Gallant  has 
worked  out  a  table  of  "  approximate  ages  "  at  which  the  menopause  should 
normally  occur,  the  age  at  which  menstruation  first  appeared  being  known. 
These  figures  refer  to  women  who  are  free  from  any  form  of  disease,  pelvic 
or  otherwise.     The  table  is  as  follows : 

Year  in  tvhich  menses  appeared  Year  in  zvhich  menopause  should  occur 

loth 50th  and  52nd 

nth 48th  and  50th 

I2th 46th  and  48th 

13th 44th  and  46th 

14th 42nd  and  44th 

15th 40th  and  42nd 

i6th 38th  and  40th 

17th 36th  and  38th 

i8th 34th  and  36th 

19th 32nd  and  34th 

20th 30th  and  32nd 

If  menstruation  continues  very  long  after  the  expected  age  the  possibility 
of  some  pathological  condition  being  present  should  be  borne  in  mind. 

Maternity. —  According  to  Sanes  the  climacterium  is  usually  late  in 
the  case  of  women  who  have  led  an  active  sexual  life,  especially  if  they 
have  given  birth  to  a  number  of  children.  On  the  other  hand,  it  is  apt  to 
occur  early  in  unmarried  women. 

Climate. —  It  is  stated  that  the  climacteric  occurs  earlier  in  the  women  of 
cold  climates  than  those  of  the  tropics.  Inasmuch  as  menstruation  is  said 
to  make  its  appearance  earlier  in  hot  countries  than  in  cold,  this  fact,  if  it 
be  a  fact,  can  be  explained  only  on  the  assumption  that  the  duration  of  the 
•  entire  reproductive  period  is  shorter  in  cold  than  in  warm  climates. 


128  MENSTRUATION  AND  ITS  DISORDERS 

Race. —  Although  statistics  bearing  on  this  point  are  meager  and  rather 
contradictory,  it  seems  to  be  true  that  certain  races  and  nationaHties  exhibit 
an  earher  average  age  of  menopause  than  others.  To  ilhistrate,  the  Arab 
women  of  the  desert  are  cited  as  examples  of  those  showing  a  character- 
istically early  menopause,  this  not  infrequently  being  observed  between  the 
ages  of  20  and  30. 

Heredity. —  An  unusually  early  or  an  unusually  late  menopause  is  said 
to  be  noted  in  certain  families  as  a  hereditary  trait.  Examples  of  such 
families  are  cited  by  Currier  and  others. 

Social  Condition. —  The  menopause,  as  a  general  rule,  occurs  earlier  in 
poor,  hard  working  women  than  those  living  in  idleness  or  in  luxurious 
surroundings. 

Obesity. —  It  has  long  been  known  that  the  menopause  is  frequently  seen 
at  a  very  early  age  in  stout  women,  although  the  explanation  for  this  fact 
is  comparatively  recent.  Cases  of  this  type  are  now  looked  upon  as  due  to 
a  deficiency  of  the  pituitary  secretion,  producing  the  "  adiposogenital 
dystrophy  "  of  Frohlich.  The  two  most  prominent  symptoms  of  the  latter 
are  obesity  and  sexual  hypoplasia,  manifesting  itself  in  the  women  as  scanty 
menstruation  or  an  actual  cessation  of  the  process.  This  subject  is  treated 
more  fully  in  Chapter  XVIII.  In  these  cases  menstruation  often  ceases  at 
an  unusually  early  age.  I  have  seen  the  menopause  occur  as  early  as  the 
age  of  23  in  cases  of  this  type. 

Wasting  Diseases. —  General  diseases  associated  with  wasting  and  gen- 
eral debility  tend  to  bring  about  an  earlier  menopause  than  usual,  the  cessa- 
tion of  the  function  in  such  cases  being  apparently  an  effort  on  the  part  of 
nature  to  conserve  the  strength  of  the  woman. 

Pelvic  Disease. —  In  the  great  majority  of  cases  the  effect  of  local 
disease  in  the  pelvis  is  to  delay  the  occurrence  of  the  menopause.  Among 
pelvic  conditions  capable  of  producing  this  effect  are  cancer,  other  uterine 
neoplasms,  polypoid  endometritis,  adnexal  inflammations,  ovarian  neo- 
plasms, etc.  Rarely  pelvic  disease  may  bring  about  the  early  disappearance 
of  menstruation.  This  is  illustrated  by  a  case  of  my  own  —  that  of  a 
woman  of  34,  in  whom  the  disappearance  of  the  menstrual  flow  was  brought 
about  by  the  presence  of  bilateral  dermoid  cysts  of  the  ovaries,  destroying 
practically  all  ovarian  substance. 

Early  Menopause. —  Many  cases  are  recorded  in  the  literature  of 
unusually  early  menopause.  Kisch,  for  example,  speaks  of  a  Hungarian 
Jewess,  fat  from  childhood,  who  menstruated  at  the  age  of  9,  married  at\ 
the  age  of  15,  was  sterile,  and  ceased  menstruating  at  the  age  of  17.  In 
another  case  of  the  same  type,  he  states  that  menstruation  occurred  at  13, 
marriage  at  16,  and  the  menopause  at  20.  Mayer  reports  2  cases  in  Berlin 
in  which  menstruation  ceased  at  22.  One  of  these  is  interesting  in  that 
three  children  were  born  after  the  menopause.  In  2  other  cases  of  Mayer 
menopause  occurred  at  25.  One  of  these  menstruated  once  in  her  twenty- 
fifth  year,  after  her  second  labor;    she  subsequently,  after  a  severe  fright, 


THE  MENOPAUSE  129 

became  idiotic.  In  still  another  of  Mayer's  cases  the  menopause  occurred 
at  the  age  of  29  in  a  very  stout  wfoman  who  had  previously  borne  six 
children.  I  have  already  spoken  of  the  case  of  my  own,  in  which  menstrua- 
tion ceased  at  the  age  of  2t,  in  a  woman  who  had  borne  three  children.  I 
have  records  of  a  number  of  other  less  pronounced  cases,  in  some  of  which 
obesity  was  present  and  in  some  of  which  it  was  absent. 

Delayed  Menopause. —  In  probably  more  than  10  per  cent  of  all  cases 
menstruation  does  not  cease  until  after  the  fiftieth  year  of  life,  but  it  is 
uncommon  for  it  to  continue  beyond  the  age  of  55.  I  have  seen  one  case 
in  which  the  menopause  did  not  occur  until  after  the  age  of  57,  but  many 
in  which  it  took  place  beyond  the  age  of  50.  Numerous  more  or  less 
remarkable  cases  of  delayed  menopause  are  to  be  found  in  the  literature. 
Currier  has  collected  quite  a  number.  One  of  the  most  remarkable  of  these 
is  the  case  reported  by  Battey  of  a  woman  93  years  old  who  still  men- 
struated regularly.  Another  of  equal  or  greater  interest  is  that  of  Pitou, 
whose  patient  menstruated  six  months  during  her  seventy-second  year, 
then  became  pregnant,  and  aborted  at  the  second  month,  the  fetus  being 
recovered.  Sumpter  reports  4  cases  of  regular  menstruation  in  women  of 
60,  70,  yy  and  80  years.  Royle  speaks  of  2  cases  in  which  the  climacteric 
occurred  at  Sy  and  93,  and  Norton  of  one  in  which  it  was  observed  at  67. 
Finally,  Neuman  has  collected  a  number  of  reports  of  cases  from  various 
sources,  in  which  the  menopause  occurred  at  ages  ranging  from  60  to  104. 
In  spite  of  these  reports,  the  fact  remains  that  it  is  rare  for  menstruation  to 
continue  as  late  as  the  sixtieth  year,  and  cases  of  this  kind  which  are 
reported  should  be  subjected  to  close  scrutiny  as  to  the  authenticity  of  the 
age  and  the  genuineness  of  the  menstrual  flow. 

The  Surgical  Menopause. —  It  has  long  been  a  guiding  principle  in 
gynecologic  surgery  to  avoid  complete  removal  of  ovarian  tissue  in  young 
women  for  fear  of  bringing  on  an  artificial  menopause,  with  its  train  of 
untoward  symptoms.  The  usual  teaching  has  been  that  the  surgical  meno- 
pause thus  produced  is  usually  sharper  and  more  severe  than  the  normal 
climacterium.  There  is  much  evidence,  chiefly  clinical,  against  the  correct- 
ness of  this  view.  It  is  a  well  known  fact,  as  Culbertson  states,  that  the 
effect  of  castration  on  young  women  is  often  surprisingly  slight.  Of  the 
correctness  of  this  statement  I  am  convinced,  as  a  result  of  many  personal 
observations.  Culbertson  remarks  that  not  one  of  a  considerable  series  of 
young  women  in  whom  both  ovaries  had  been  removed  suffered  sufficiently 
to  induce  her  to  continue  treatment. 

Others  who  have  emphasized  the  relative  mildness  of  the  artificial  as 
compared  with  the  natural  menopause  are  Graves,  Pfister,  and  Fehling. 
Graves  believes  that  the  so-called  menopausal  vasomotor  symptoms  are 
observed  with  practically  the  same  frequency  after  removal  of  the  uterus, 
either  with  or  without  removal  of  the  ovaries,  as  after  total  ablation  of 
ovarian  tissue  alone.  He  ascribes  the  causation  of  these  symptoms  not  to 
liiere  withdrawal  of  the  ovarian  hormone,  but  to  a  "  break  in  the  utero- 


130  MENSTRUATION  AND  ITS  DISORDERS 

ovarian  functional  harmony  ".  He  therefore  considers  that  there  is  no 
advantage  in  conserving  ovarian  tissue  when  hysterectomy  is  necessary, 
and  that  such  retention  may  be  actually  harmful. 

The  practical  importance  of  this  question  is  great.  It  is  probable  that 
most  surgeons,  appreciating  the  internal  secretory  function  of  the  ovary, 
will  still  continue  to  practice  conservation  of  healthy  ovarian  tissue  when- 
ever possible.  On  the  other  hand,  important  as  the  ovary  is,  it  is  by  no 
means  essential  to  life  or  to  the  maintenance  of  good  health,  and  ultra- 
conservatism  may  sometimes  work  more  harm  to  the  patient  than  so-called 
radicalism.  The  course  to  be  followed  in  the  individual  case  must  be  influ- 
enced by  many  other  factors  than  the  mere  consideration  of  the  physiological 
function  of  the  ovary.  Most  important  among  these  factors  are  the  im- 
portance to  the  patient  of  future  childbirths,  the  character  and  extent  of  the 
pelvic  lesions,  the  patient's  age  and  her  economic  and  social  status.  For  a 
fuller  discussion  of  this  subject  the  reader  is  referred  to  the  papers  of 
Culbertson,  Graves,  Schickele,-  Polak,  and  others. 

Duration  of  Menopause.- —  There  are  marked  Individual  variations  in 
the  duration  of  the  menopausal  period.  It  must  be  borne  in  mind  that  the 
cessation  of  the  menstrual  function  is  only  one,  though  perhaps  the-  most 
striking,  of  a  whole  group  of  changes  which  mark  the  retrogression  of  the 
reproductive  function.  Properly  speaking,  the  menopause  embraces  all 
these  various  phenomena,  and  from  this  viewpoint,  its  duration  is  from  a 
few  months  to  several  years.  Occasionally  cases  are  seen  in  which  the 
onset  of  the  menopause  is  very  abrupt  and  its  duration  brief.  Much  more 
frequently,  however,  its  course  is  more  gradual,  and  its  duration  therefore 
considerably  longer.  The  average  duration  may  be  placed  at  from  two  to 
two  and  a  half  years. 

Symptoms  of  the  Menopause. —  General  Course. —  Before  describ- 
ing the  various  symptoms  of  the  menopause  in  detail.  It  may  be  well  to 
sketch  briefly  the  course  it  pursues  In  what  may  be  considered  a  fairly 
typical  case.  As  the  woman  approaches  the  climacteric  age,  even  while 
the  menstrual  function  is  still  regular,,  she  Is  apt  to  experience  more  or  less 
of  the  vasomotor  disturbance  which,  next  to  the  disappearance  of  the  menses, 
is  the  most  Important  manifestation  of  the  menopause.  From  time  to  time 
there  will  be  an  intense  though  transitory  flushing  of  the  head  and  neck, 
accompanied  by  a  sensation  of  flashing  heat.  This  is  frequently  followe^d 
by  sweating,  sometimes  copious.  The  temperament  of  the  woman  is  qult^: 
likely  to  undergo  some  change,  though  only  exceptionally  is  this  very 
profound.  Usually  this  change  is  evidenced  only  by  unusual  nervousness. 
Irritability,  and  peevishness.  By  this  time  there  has  probably  been  more  or 
less  disturbance  of  the  menstrual  rhythm.  Whereas  the  menses  have  been 
recurring  at  regular  four  week  Intervals,  and  have  been  lasting  perhaps 
four  or  five  days,  they  now  become  usually  more  scanty,  lasting  only  a  day 
or  two,  and  there  may  be  a  complete  skipping  of  one  period.  This  may  be 
followed  by  scanty  menstruation  for  a  month  or  two,  and  then  will  come 


THE  MENOPAUSE  131 

another  period  of  amenorrhea.  In  this  gradual  manner  the  menstrual 
function  tapers  off  into  complete  disappearance.  The  vasomotor  symptoms 
usually  continue  for  a  longer  or  shorter  time  after  the  cessation  of  men- 
struation, their  disappearance  also  being  gradual  as  a  rule.  In  the  majority 
of  cases  there  is  a  tendency  to  laying  on  of  adipose  tissue,  sometimes  amount- 
ing to  an  actual  obesity. 

This  description  will  apply  to  the  case  of  moderate  severity.  With  some 
women,  however,  the  symptoms  are  so  slight  as  to  be  practically  negligible. 
With  the  exception  of  the  cessation  of  the  menses  and  perhaps  an  occasional 
slight  flush,  no  other  symptoms  may  be  observed.  In  other  cases,  on  the 
other  hand,  the  menopause  may  bring  about  the  most  violent  upheaval  in 
the  woman's  mental  and  physical  make-up.  The  vasomotor  disturbances 
may  be  exceedingly  annoying,  while  the  psychic  changes  may  be  most  dis- 
tressing, amounting  in  rare  cases  to  an  actual  insanity  of  one  type  or 
another,  when  there  is  a  hereditary  tendency  in  this  direction.  AVe  shall 
now  consider,  in  greater  detail,  some  of  the  important  symptoms  of  the 
menopause. 

Cessation  of  Menstruation. —  Whatever  other  symptoms  a  woman 
may  exhibit  at  this  period,  certainly  the  one  which  gives  the  menopause  its 
name  —  the  cessation  of  menses  —  is  the  most  characteristic.  As  already 
emphasized,  it  is  only  one  manifestation  of  a  retrogressive  change  involving 
the  entire  reproductive  apparatus,  just  as  the  initiation  of  the  menstrual 
function  at  puberty  is  only  one  of  the  signs  of  the  awakening  of  the  sexual 
life  which  marks  that  period.  Occasionally  the  menstrual  function  may  stop 
very  suddenly,  but  such  cases  are  unusual.  Far  more  frequently,  the 
cessation  of  menstruation  is  gradual,  as  described  above,  many  months 
frequently  elapsing  before  the  "  dodging  period  "  gives  way  to  a  complete 
and  permanent  disappearance  of  the  flow. 

It  will  be  noticed  that  no  mention  has  been  made  of  excessive  hemorrhage 
as  a  symptom  of  the  menopause.  As  a  matter  of  fact,  the  dictum  has  been 
laid  down  that  "  menorrhagia  and  metrorrhagia  are  never  caused  by  the 
menopause,"  to  quote  one  author.  In  my  opinion,  this  statement  is  true 
only  when  properly  qualified.  There  is  no  question  that  not  infrequently 
uterine  hemorrhage  occurs  at  the  time  of  the  menopause  In  the  entire 
absence  of  any  demonstrable  anatomical  change  In  the  uterus  or  other  pelvic 
organs,  as  will  be  shown  In  Chapter  XXII.  Such  cases  of  "  climacteric 
hemorrhage  "  are  explained  as  being  due  to  a  physiological  lesion  rather 
than  an  anatomical  one.  The  disturbance  in  these  cases  undoubtedly  in- 
volves some  portion  of  the  ductless  gland  chain,  being  obviously  due  to  the 
withdrawal  of  the  ovarian  secretion.  There  is  thus  produced  a  disturbance 
of  the  hormone  equilibrium,  which  sometimes  results  In  bleeding.  The 
condition  Is  analogous  to  that  which  occurs  at  puberty,  when  the  ovary 
begins  to  functionate,  the  changed  conditions  In  the  ductless  gland  circuit 
sometimes  causing  pathological  bleeding  —  the  so-called  "  hemorrhages  of 
puberty." 


132  MENSTRUATION  AND  ITS  DISORDERS 

Looked  at  in  this  light,  it  can  scarcely  be  said  that  the  menopause  in  itself 
is  never  responsible  for  menorrhagia  or  metrorrhagia,  although  it  cannot 
be  too  strongly  emphasized  that  such  an  explanation  for  the  bleeding  should 
never  be  assumed  until  more  dangerous  anatomical  causes  are  excluded. 
This  applies  especially,  of  course,  tO'  cancer,  which  so  frequently  manifests 
itself  first  at  this  age  by  excessive  menstruation.  In  view  of  its  great 
frequency  and  its  great  danger  every  case  of  excessive  menstruation  at  or 
near  the  time  of  the  menopause  should  be  looked  upon  as  cancer  until  proved 
to  be  otherwise. 

Vasomotor  Symptoms. —  Most  conspicuous  among  these  are  the  peculiar 
ffusJics  which  affect  usually  only  the  head  and  neck,  but  which  sometimes 
are  general  over  the  entire  body.  Associated  with  them  are  the  hot  flashes 
which  come  frequently  over  the  entire  body,  although  these  too  are  usually 
most  marked  in  the  head  and  neck.  When  these  come  on,  the  patient 
experiences  a  sensation  of  stifling  heat,  so  that  in  pronounced  cases  it  is  not 
unusual  to  be  told  that  on  a  cold  day  the  patient  rushes  to  an  open 
window  for  a  breath  of  cold  air.  The  duration  of  the  flashes  is  commonly 
short,  seldom  more  than  a  few  minutes.  Their  frequency  is  very  variable, 
both  in  different  individuals  and  in  the  same  Individual  at  different  times 
during  the  course  of  the  menopause.  When  severe,  they  may  recur  a  num- 
ber of  times  a  day,  while  in  mild  cases,  on  the  other  hand,  they  may  occur 
only  at  intervals  of  many  days.  When  mild  in  degree,  the  patient  experi- 
ences only  a  sensation  of  warmth  and  flushing  about  the  face.  Associated 
with  the  flushes  and  the  flashes,  usually  immediately  following  them,  there 
is  apt  to  be  more  or  less  copious  sweating.  This,  however,  is  frequently 
absent. 

Among  other  symptoms  which  are  probably  referable  to  the  vasomotor 
system  are  vertigo,  faintness,  palpitation  of  the  heart,  epistaxis,  vicarious 
bleedings  from  various  parts  of  the  body,  cold  hands  and  feet,  etc.  Some 
of  these  vasomotor  symptoms  are  found  in  almost  every  case  —  certainly 
in  over  80  per  cent  of  all  cases.  The  flushes  and  the  heat  flashes  are  the 
most  frequent  and  most  characteristic  of  the  disturbances. 

A  satisfactory  explanation  of  how  these  interesting  phefiomenat  are 
brought  about  is  not  possible  in  the  present  state  of  our  knowledge.  \Like 
the  other  symptoms  oi  the  menopause,  they  are  obviously  due  to  the  with- 
drawal of  the  ovarian  secretion,  but  just  how  the  absence  of  the  latter  affects 
the  vasomotor  system  is  not  as  yet  fully  worked  out.  A  discussion  of  the 
relations  between  the  vasomotor  apparatus  and  the  ductless  gland  chain 
will  be  found  in  Chapter  XXII.  Here  it  need  only  be  said  that  the  ovary  is 
of  course  intimately  associated  with  all  the  other  organs  which  possess  inter- 
nal secretions,  and  that  the  latter  are  in  turn  closely  related  with  the  sym- 
pathetic nervous  system,  which  embraces  the  vasomotor  apparatus.  These 
facts  have  been  abundantly  proved  in  the  case  of  the  thyroid  and  suprarenal 
especially.  We  are  unable  as  yet  to  explain  the  workings  of  this  intricate 
mechanism,  but  the  knowledge  we  already  possess  enables  us  to  recognize 


THE  MENOPAUSE  133 

an  avenue  of  approach  to  the  vasomotor  centre  from  the  ovary.  The  vaso- 
motor centre,  as  is  well  known,  is  closely  related  with  the  heat  centre  or 
centres,  and  this  fact  led  Byron  Robinson  to  suggest  that  the  heat  flashes 
so  often  associated  with  the  flushes  are  due  to  a  coincident  effect  produced 
upon  the  heat  centres.  In  the  same  way,  the  excessive  perspiration  some- 
times noted  has  been  explained  as  being  due  to  a  similar  effect  upon  the 
sweat  centre,  which  lies  close  to  the  vasomotor  centre  in  the  floor  of  the 
fourth  ventricle. 

In  a  study  of  the  relation  of  menstrual  vertigo  to  blood  pressure,  Sanes 
found  that  only  46  per  cent  of  102  cases  had  a  pressure  above  150,  and  only 
30  per  cent  above  160. 

As  the  result  of  a  recent  exhaustive  study,  Culbertson  concludes  that  these 
vasomotor  disturbances  "  represent  an  instability  of  arterial  tension."  He 
states  furthermore  that  the  ovarian  deficiency  of  the  menopause  causes  a 
relative  oversufficiency  of  the  pituitary  and  adrenals,  thus  causing  a  "  vacil- 
lating hypertension."  Since  the  diastolic  pressure  is  not  increased  hand  in 
hand  with  the  systolic,  there  is  produced  an  increase  in  the  pulse  pressure. 
To  these  fluctuations  of  the  arterial  tension,  he  ascribes  the  vasomotor 
symptoms  of  the  menopause. 

Psychic  Symptoms. —  In  the  mildest  cases  there  appears  to  be  no  change 
in  the  disposition  of  the  woman.  In  perhaps  the  majority  of  cases,  how- 
ever, there  are  psychic  manifestations  of  one  form  or  another,  sometimes 
grave.  Some  women  become  peevish  and  irritable,  others  morose  and 
depressed.  In  the  most  severe  cases,  which  fortunately  are  rather  rare, 
actual  insanity  may  supervene,  especially  where  there  is  a  hereditary 
tendency.  This  may  take  any  one  of  a  number  of  forms,  melancholia  and 
paranoid  conditions  being  most  common  in  my  experience,  although  the 
various  maniacal  conditions  are  not  rare.  This  subject,  however,  will  be 
more  fully  discussed  in  Chapter  XV. 

Nervous  Symptoms, —  Aside  from  the  general  nervous  irritability,  there 
are  many  possibilities  as  regards  special  symptoms  referable  to  the  nervous 
system.  One  of  the  most  interesting  of  these,  though  not  a  very  frequent 
one,  is  tachycardia.  Knowing  how  constantly  this  phenomenon  is  associated 
with  hyperthyroidism,  one  is  tempted  to  believe  that  perhaps  its  occurrence 
at  the  climacterium  is  to  be  explained  by  a  relative  hyperthyroidism,  as  a 
result  of  the  withdrawal  from  the  circulation  of  the  ovarian  secretion. 
That  the  thyroid  is  intimately  associated  with  the  nervous  system,  and 
especially  with  the  sympathetic,  is  well  known,  hence  the  tachycardia  would 
seem  to  be  due  to  a  stimulation  of  the  cardiac  sympathetic  nerves  rather  than 
an  inhibition  of  the  vagus.  Palpitation  of  the  heart  is  also  frequently  com- 
plained of,  either  with  or  without  tachycardia. 

Many  patients  complain,  sometimes  persistently,  of  sensations  of  numb- 
ness or  tingling  in  various  parts  of  the  body,  most  often  the  upper  extrem- 
ities. Another  frequent  and  troublesome  symptom  is  pruritus,  sometimes 
general  and  sometimes  confined  to  the  genitalia.    In  severe  cases,  the  patient 


134  MENSTRUATION  AND  ITS  DISORDERS 

is  made  quite  frantic  by  the  intolerable  itching,  which  is  often  intractable  to 
all  the  usual  forms  of  treatment  by  nerve  sedatives  and  local  applications. 
In  a  recent  case  of  my  own,  the  pruritus  was  associated  with  and  perhaps 
due  entirely  to  a  chronic  urticarial  eruption  involving-  the  entire  skin  sur- 
face, including  the  face  and  scalp.  The  irritability  of  the  bladder  so  often 
seen  at  the  time  of  the  menopause  appears  in  some  cases  to  be  entirely  of 
nervous  origin. 

Last,  but  not  least,  in  this  group  of  symptoms,  must  be  mentioned  head- 
ache and  vertigo.  Especially  annoying  is  the  former.  The  headache  of  the 
menopause  is  not  uncommonly  vertical  or  occipital,  and  sometimes  exhibits 
a  peculiar  periodicity.  A  patient  recently  under  observation  dreaded  the 
approach  of  Sunday  afternoon,  which  invariably  brought  with  it  a  severe 
attack  of  headache.  In  such  cases,  of  course,  the  psychic  element  no  doubt 
plays  an  important  part.  In  many  instances  the  headache  is  accompanied 
by  nausea  or  vomiting.  The  frequency  of  the  attacks  is  very  variable,  as  is 
their,  duration.  In  both  these  respects,  the  general  nervous  tone  of  the 
woman  plays  a  part  of  much  importance.  In  the  case  of  delicate  and  highly 
neurotic  women,  there  is,  of  course,  a  much  greater  susceptibility  to  frequent 
and  stubborn  headaches  than  in  the  case  of  women  who  are  naturally  more 
or  less  robust.  What  has  been  said  of  headaches  applies  in  the  main  to 
vertigo,  another  common  symptom  of  the  menopause.  Absent  in  some 
women,  it  is  in  others  a  symptom  of  great  annoyance. 

Other  Symptoms. —  Some  form  of  gastric  disturbance  Is  frequently 
noted  at  the  time  of  the  menopause.  Many  years  ago  Kisch  wrote  of  a 
dyspepsia  utcrina,  especially  frequent  at  this  period.  It  must  of  course  be 
borne  in  mind  that  for  many  cases  of  "  indigestion  "  noted  at  this  period 
there  is  some  definite  anatomic  cause,  such  as  gallstones,  gastric  or  duodenal 
ulcer,  or  cancer  of  the  stomach.  Constipation  is  frequently  noted,  diarrhea 
being  less  common.  The  study  and  treatment  of  gastro-intestinal  disorders 
at  the  climacterium  offers  a  splendid  opportunity  for  cooperation  between 
the  gynecologist  and  the  gastro-enterologlst  or  internist. 

In  some  cases  there  is  an  Increase  In  the  sexual  appetite,  and  it  is  said 
that  some  women  who  before  this  period  have  been  sexually  frigid,  at  this 
time  become  very  passionate. 

Skin  eruptions  of  one  form  or  another  are  occasionally  seen  at  the  time 
of  the  menopause,  the  most  frequent  form  being  urticaria.  Acne  may  be 
observed,  but  it  is  much  more  rare  than  at  the  time  of  puberty. 

Factors  Influencing  the  Severity  of  the  Menopause, —  From  the 
above  recital  of  the  principal  possibilities  in  the  clinical  course  of  the  meno- 
pause, one  might  get  the  impression  that  It  represents  a  distinctly  patho- 
logical period.  Such,  however,  is  not  the  case.  It  can  not  be  too  strongly 
emphasized  that  the  menopause,  like  puberty,  is  one  of  the  physiological 
epochs  of  a  woman's  life.  Some  one,  with  greater  or  less  justification,  has 
compared  It  with  childbirth,  which,  while  It  is  a  physiological  process.  In- 
volves much  pain  and  suffering.     In  the  same  way,  it  may  be  conceded  that 


THE  MENOPAUSE  135 

the  menopause  also  represents  a  physiological  transition  period,  but  it  can 
not  be  denied  that  it  may  involve  much  annoyance  and  distress  on  the  part 
of  the  woman.  In  some  cases  this  is  insignificant,  in  others  distressing. 
The  principal  factors  which  influence  the  severity  of  the  menopause  are  so 
well  set  forth  by  Currier  that  I  can  do  no  better  than  quote  him.  He  says 
"  All  that  tends  to  develop  and  strengthen  the  physical  part  of  woman  —  to 
render  her  insensitive  to  the  ordinary  ills  of  life,  to  make  her  forgetful  of 
'  self  —  is  favorable  to  a  normal  menopause.  Races  and  nations  which  are 
phlegmatic,  cold  and  apathetic,  women  who  are  inured  to  out  of  door  life 
and  severe  manual  labor,  savage  and  barbarous  women,  peasants,  Germans, 
Scandinavians,  and  Russians,  are  apt  to  complain  little  of  the  experiences  of 
the  menopause;  while  the  sensitive  passionate  nations,  like  the  French, 
Spanish,  and  Irish,  the  highly  organized,  nervous,  city  bred  women,  w^omen 
of  fashion,  women  who  fret  and  worry,  are  apt  to  experience  the  disagree- 
able and  annoying  features  of  the  menopause."  Speaking  of  the  moderately 
troublesome  cases,  he  says  "  The  number  of  women  who  belong  to  this 
class  is  very  large.  It  includes  w^omen  who  have  had  a  stormy  menstrual 
life,  wiio  have  suffered  much  with  dysmenorrhea,  who  have  suffered  much 
with  anemia,  headache,  and  constipation.  It  also  includes  women  who  have 
been  addicted  to  venereal  excesses,  who  have  had  frequent  abortions,  w^hose 
nervous  systems  have  suffered  frequent  shocks,  who  have  had  great  disap- 
pointments, whose  lives  have  been  a  constant  worry  and  unrest,  also  women 
who  have  undergone  privation,  overwork,  and  exposure  of  various  kinds. 
Among  them  will  be  found  many  shopwomen,  many  prostitutes,  women  of 
fashion,  women  w-ho  bring  up  large  families  of  children  on  very  slender 
incomes,  women  who  are  hysterical  and  with  whom  the  affairs  of  life  are 
constantly  going  wrong,  wives  of  farmers  and  mechanics  who  are  frequently 
troubled  to  make  ends  meet." 

Anatomic  Changes  of  the  Menopause. —  All  the  anatomic  changes 
demonstrable  in  various  organs  at  the  menopause  are  indicative  of  the  uni- 
versal retrogression  which  characterizes  this  period. 

External  Genitalia. —  Marked  atrophic  changes  are  seen  in  the  tissues 
of  the  vulva.  The  fat  of  which  the  labia  are  so  largely  made  up  disappears 
almost  entirely,  so  that  they  become  little  more  than  two  long  skin  folds,  so 
flat  in  many  instances  as  to  be  scarcely  noticeable.  The  hair  on  their  outer 
surfaces  becomes  gray  and  straggly.  As  a  result  of  the  atrophy  of  the  labia 
majora,  the  labia  minora  become  relatively  more  prominent,  as  in  the  child, 
even  though  they  also  undergo  more  or  less  wasting.  The  clitoris  becomes 
very  small,  the  glans  clitoridis  being  often  scarcely  demonstrable  in  the 
bifurcation  of  the  labia  minora.  As  a  result  of  the  so-called  senile  atrophy, 
with  its  attendant  thinning  of  the  epithelial  layer,  the  mucous  membrane  of 
the  vulva  loses  its  velvety,  vascular  appearance,  and  becomes  thin,  pale,  and 
transparent  looking,  giving  the  surface  a  rather  pasty  appearance.  Patches 
of  catarrhal  inflammation  are  often  seen  mottling  the  surface  (senile  vul- 
vitis).     The  meatus  urinarius  is  often  granular  looking,  and  not  infre- 


136 


MENSTRUATION  AND  ITS  DISORDERS 


quently  is  everted.     The  mons  veneris,  like  the  labia  majora,  becom€s  lOw  as 
a  result  of  the  disappearance  of  its  fat. 

The  vagina  becomes  narrow  and  contracted,  the  result  of  the  same  process 
of  senile  atrophy,  in  which  there  is  a  replacement  of  parenchymatous  by 
interstitial  tissue.  Annular  lines  of  contraction  are  frequently  noted,  and 
occasionally  the  lumen  of  the  canal  may  be  almost  or  quite  obliterated.  The 
fornices  of  the  vagina  become  narrow  and  conical,  the  apex  of  the  cone 
corresponding  to  the  cervix.  The  vaginal  mucosa,  like  that  of  the  vulva, 
becomes  thin  and  atrophic. 


Fig.  26. —  Senile  Endometrium  from  a  Patient  Aged  49  Years. 


Internal  Genitalia. —  The  cervix  uteri  becomes  very  small  and  shoTt, 
often  feeling  like  a  small  button  set  in  the  top  of  the  vaginal  fornix.  The 
external  os,  especially  in  nulliparous  women,  becomes  so  narrow  as  scarcely 
to  be  distinguishable.  The  corpus  uteri  shares  in  the  general  atrophic 
change,  becoming  small  and  hard.  The  muscular  structure  of  the  myome- 
trium is  to  a  considerable  extent  replaced  by  connective  tissue. 

Especially  noteworthy,  however,  are  the  changes  in  the  endometrium, 
which  becomes  thin  and  avascular.  The  glands  lose  their  full  tortuous 
appearance  and  become  straight  and  narrow.  (Fig.  ^^-^  The  increase  in 
the  connective  tissue  often  causes  an  encroachment  upon  the  glands,  some- 


THE  MENOPAUSE  137 

times  even  obliterating  their  lumina,  and  occasionally  causing  small  gland- 
ular retention  cysts.  The  epithelium  lining  the  utricular  glands,  as  well 
as  that  covering  the  surface,  becomes  low  and  cuboidal.  In  extreme  cases, 
it  is  almost  flat,  like  squamous  epithelium.  This  transformation  is  con- 
sidered by  some  to  explain  the  occasional  occurrence  of  squamous  cell 
carcinoma  of  the  corpus  uteri,  a  few  authentic  cases  of  which  have  been 
recorded. 

The  stroma,  normally  made  up  of  round  or  oval  cells,  shows  the  presence 
of  increasing  numbers  of  spindle  cells.  Under  the  microscope  these  can 
usually  be  seen  traversing  the  field  in  long  streaky  looking  bands.  In  very 
old  women,  the  stroma  consists  of  what  is  virtually  ordinary  connective 
tissue. 

The  fallopian  tubes  also  participate  in  the  retrogressive  processes  of  the 
menopause,  becoming  shorter  and  thinner.  The  fimbriae  disappear  or 
become  very  inconspicuous,  as  do  also  the  longitudinal  rugae  in  the  mucosa. 
Miscroscopically  the  epithelium  is  seen  to  have  undergone  a  flattening  simi- 
lar to  that  observed  in  the  uterus,  while  the  muscle  tissue  in  the  walls  is  in 
large  measure  replaced  by  connective  tissue. 

In  the  ovaries  striking  changes  are  observed  at  and  after  the  menopause. 
While  occasionally  the  size  of  the  ovary  is  not  much  changed,  in  the 
majority  of  instances  the  organ  is  much  diminished  in  size,  perhaps  to  only 
one  half  or  one  third  of  its  original  size.  This  gives  it  a  peculiar  beady 
feel  on  bimanual  examination.  The  surface  is  not  glistening  as  in  the  case 
of  the  ovary  of  the  young  woman,  being  now  of  an  opaquely  white  appear- 
ance. The  peculiar  wrinkling  of  the  surface  so  generally  noted  at  this  time 
reminds  one  of  the  appearance  of  the  surface  of  a  peach  stone.  When  the 
senile  ovary  is  cut  across,  its  surface  is  found  to  be  firm  and  dense,  owing 
to  the  preponderance  of  connective  tissue.  Numerous  cicatrical  islands, 
usually  of  rather  scalloped  appearance,  mark  the  sites  of  former  corpora 
lutea.  The  differentiation  between  cortex  and  medulla  becomes  well 
marked.     Fig.  2y  illustrates  the  appearance  of  a  section  of  the  senile  ovary. 

Other  Changes. —  The  breast  glands,  so  intimately  bound  up  with  the 
generative  organs  physiologically,  become  small  and  atrophic.  Sometimes 
the  breasts  not  only  do  not  diminish  in  size,  but  may  even  become  larger, 
but  this  is  due  to  a  marked  deposition  of  adipose  tissue.  The  glandular 
tissue,  however,  undergoes  atrophy,  the  acini  being  smaller  and  more 
discrete. 

As  for  the  general  appearance  of  the  woman,  the  only  conspicuous  altera- 
tion —  and  even  this  is  not  constant  —  is  a  tendency  to  a  general  increase 
of  the  adipose  tissue.  The  figure  therefore  is  usually  more  rounded  and 
matronly,  and  often  actual  obesity  develops.  In  other  cases,  on  the  other 
hand,  the  woman  loses  weight,  and  if  thin  before,  becomes  even  more  spare 
and  angular. 

Diagnosis. —  In  the  great  majority  of  cases,  there  is  no  difficulty  in 
recognizing  the  occurrence  of  the  menopause.     As  a  rule  the  woman  who 


138 


MENSTRUATION  AND  ITS  DISORDERS 


has  reached  the  age  at  which  it  usually  occurs  is  prepared  for  its  incidence, 
and  if  not,  she  is  apt  to  receive  due  warning  in  the  form  of  the  vasomotor 
flushes  which  so  often  precede  the  actual  cessation  of  menstruation.  When 
the  latter  phenomenon  is  noticed,  therefore,  it  excites  no  great  concern,  and 
many  women  do  not  even  consult  the  physician.  In  a  certain  percentage 
of  cases,  however,  it  becomes  necessary  to  decide  whether  the  cessation  of 
menstruation  is  an  indication  of  the  onset  of  the  menopause,  or  whether  it 


Fig.  27. — 'Senile  Changes  as  Seen  on  Transverse  Section  of  Ovary   (patient  aged 

48  years). 

Note  dense,  well  defined  cortex,  as  contrasted  with  the  medulla.  The  hilum  is  seen  below 
and  to  the  right. 

is  only  a  temporary  amenorrhea  due  to  some  other  cause.     It  is  not  always 
easy  to  make  this  differentiation. 

The  condition  which  is  most  apt  to  be  confused  with  the  menopause  is  the 
amenorrhea  of  pregnancy.  Every  physician  must  confront  this  problem 
frequently,  and  mistakes  are  not  uncommon.  Many  a  woman  who  becomes 
pregnant  after  the  age  of  40  thinks  she  is  entering  upon  the  menopause, 
until  time  or  the  physician  disillusions  her.  On  the  other  hand,  it  not 
infrequently  happens  that  the  amenorrhea  of  the  menopause  is  mistaken  for 
pregnancy,  especially  in  the  case  of  women  who  are  very  desirous  of  having 


THE  MENOPAUSE  139 

children.  The  problem  in  such  cases  is  made  much  harder  by  the  fact  that 
the  natural  tendency  of  the  menopause  is  to  make  the  woman  stouter  than 
formerly.  Many  cases  of  pseudocyesis  or  "  spurious  pregnancy "  are  of 
this  type.  Only  recently  I  had  occasion  to  examine  a  lady  of  42,  who  since 
her  marriage  at  the  age  of  35  had  been  very  anxious  to  become  a  mother. 
She  had  not  menstruated  for  six  months,  the  abdomen  had  increased  very 
much  in  size,  and  she  had  even,  she  said,  had  some  nausea  at  times.  She 
considered  herself  pregnant,  an  opinion  in  which  her  physician  concurred, 
although  no  examination  had  been  made.  She  had  made  all  her  arrange- 
ments for  the  expected  confinement,  and  it  was  difficult  to  convince  her  that 
she  was  not  pregnant.  Her  uterus  was  not  enlarged  and  was  of  the 
infantile  type.  Many  similar  cases  might  be  cited.  When  menstruation  has 
been  absent  only  a  month  or  two  the  diagnosis  can  not  usually  be  made 
with  certainty.  In  later  stages,  however,  pelvic  examination,  with  especial 
reference  to  possible  enlargement  of  the  uterus,  will  usually  clear  up  the 
diagnosis.  Other  points  of  differentiation,  such  as  absence  of  the  fetal 
heart  sounds,  need  only  be  mentioned. 

Treatment  of  Menopausal  Disturbances.— General  Measures. — 
The  higher  the  standard  of  general  health  and  resistance  v/ith  which 
the  woman  enters  upon  the  menopause,  the  better  her  chance  of  passing 
through  it  with  a  minimum  of  discomfort.  It  is  scarcely  necessary,  there- 
fore, to  dwell  at  any  length  upon  the  importance  of  such  factors  as  care  in 
diet,  proper  sleep,  bathing,  avoidance  of  constipation,  and,  especially,  the 
avoidance  of  worry  and  anxiety  of  any  sort.  Strict  insistence  by  the  physi- 
cian on  the  carrying  out  of  these  measures  and  an  intelligent  cooperation  on 
the  part  of  the  patient  will  do  much  to  mitigate  the  suffering  of  the  woman 
who  is  passing  through  this  trying  period. 

Treatment  by  Drugs. —  There  are  many  women  who  pass  through  the 
menopause  with  little  or  no  disturbance,  either  physical  or  psychic,  so  that 
the  administration  of  drugs  or  other  remedial  measures  is  never  called  for. 
On  the  other  hand,  as  we  have  seen,  it  is  common  to  find  women  suffering 
with  more  or  less  distressing  symptoms.  The  clinical  picture  is  so  different 
in  different  women  that  a  rational  treatment  of  the  condition  must  adapt 
itself  to  the  individual  needs  of  the  particular  case.  Indeed,  it  may  be  said 
that,  so  far  as  drugs  are  concerned,  the  treatment  of  the  menopause  is 
purely  symptomatic.  A  few  suggestions  may  be  made  as  regards  the  treat- 
ment of  some  of  the  more  common  symptoms. 

Hemorrhage. —  The  important  fact  to  bear  in  mind,  in  connection  with 
climacteric  hemorrhage  is,  of  course,  the  frequency  with  which  it  heralds 
the  invasion  of  uterine  cancer.  The  physician  owes  it  to  the  patient  to 
suspect  the  development  of  cancer  whenever  such  abnormal  bleeding  is 
present.  Only  the  physician  who  has  "  cancer  on  the  brain,"  as  Carstens 
puts  it,  will  be  likely  to  detect  the  disease  in  a  stage  which  still  offers  hope 
of  cure.  The  treatment  of  hemorrhage  at  the  climacterium  should  be  pri- 
marily surgical,  even  though  there  is  no  gross  evidence  of  cancer,    Explora- 


140  MENSTRUATION  AND  ITS  DISORDERS 

tory  curettage  may  reveal  the  presence  of  adenocarcinoma  oi  the  body  of 
the  uterus,  or  of  some  benign  surgical  lesion,  such  as  submucous  myoma  or 
polyp. 

If  no  anatomic  cause  for  the  bleeding  be  found  in  the  pelvis,  either  in  the 
uterus  or  in  the  adnexa,  treatment  by  various  drugs  is  frequently  resorted 
to.  Among  those  most  commonly  employed  are  ergot,  hydrastis,  pituitary 
extract,  apiol,  and  stypticin.  The  treatment  of  climacteric  hemorrhage  will, 
however,  be  more  fully  discussed  in  Chapter  XXII. 

Nervous  Symptoms. —  For  the  ''  nervousness "  which  is  so  frequently 
complained  of  at  the  menopause,  the  remedies  most  commonly  resorted  to, 
and  probably  of  the  greatest  value,  are  the  various  bromids.  Sodium  or 
potassium  bromid  in  rather  moderate  doses  (gr.  x  or  gr.  xv  three  times  a 
day),  either  alone  or  in  association  with  other  drugs,  may  be  recommended 
both  for  the  nervous  irritability  and  for  the  headache  and  neuralgia  so  often 
complained  of.  When  the  latter  symptoms  are  very  severe,  however,  relief 
may  be  more  readily  given  by  the  administration  of  aspirin  (gr.  v  to  gr.  x 
every  4  hours)  or  the  various  coal  tar  products,  such  as  acetanilld  (gr.  iii 
to  gr.  v  every  4  hours),  or  acetphenetidin  (gr.  v  to  gr.  x  every  4  hours). 
The  latter  group  of  drugs,  on  account  of  their  well  known  tendency  to  cause 
cardiac  depression  and  other  untoward  effects,  must  of  course  be  adminis- 
tered guardedly,  and  should  be  combined  with  appropriate  doses  of  caffein. 

Another  troublesome  symptom  is  insomnia.  In  addition  to  various  gene- 
ral measures,  such  as  hot  baths  at  bedtime,  avoidance  of  excitement,  plenty 
of  fresh  air,  etc.,  drugs  are  occasionally  indicated,  although  their  adminis- 
tration should  be  as  restricted  as  it  is  possible  to  make  it.  Here  again  the 
bromids  of  sodium,  potassium,  or  strontium,  are  of  value.  Another  useful 
drug  is  veronal,  given  in  doses  of  from  five  to  ten  grains  several  hours 
before  bedtime,  preferably  with  hot  milk.  Instead  of  veronal,  one  may 
employ  trional,  sulphonal  or  paraldehyd. 

In  the  comparatively  rare  cases  where  an  actual  mental  disturbance  super- 
venes, the  treatment,  of  course,  passes  over  to  the  realm  of  the  psychiatrist. 
Frequently  it  becomes  institutional,  although  the  outlook  in  cases  of  meno- 
pausal insanity  is,  in  my  own  experience,  relatively  favorable. 

Vasomotor  Symptoms. —  The  vasomotor  Hushes  and  sweats,  and  the 
■Rashes  of  heat  which  have  already  been  described  as  perhaps  the  most  char- 
acteristic phenomena  of  the  menopause,  are  entitled  to  separate,  if  brief, 
consideration.  Taken  as  a  group,  it  may  be  said  that  drug  treatment  of 
these  symptoms  is  less  satisfactory  than  in  any  other  group  of  phenomena 
observed  in  the  patient  at  the  menopause.  On  the  other  hand,  as  we  shall 
see,  it  is  in  this  group  that  the  most  striking  results  of  organotherapy  are 
noted.  The  treatment  of  these  disorders  by  organ  extracts  is  discussed  in 
Chapter  XXVI. 

Of  the  drugs  used  for  these  vasomotor  disturbances  may  be  mentioned 
the  bromids,  arsenic,  ergot,  and  belladonna.  Except  in  the  case  of  bromids, 
it  is  difficult  to  suggest  a  pharmacodynamic  basis  for  the  employment  of 


THE  MENOPAUSE  141 

these  drugs.  Arsenic,  usually  administered  in  the  form  of  Fowler's  solu- 
tion, is  said  to  be  especially  indicated  when  the  patient  is  anemic. 

Eng-elhorn  has  recently  reported  good  results  from  venesection  in  a  num- 
ber of  cases  in  which  menopausal  symptoms  were  troublesome.  The  annoy- 
ing "  hot  flashes,"  sensations  of  heat,  and  the  attacks  of  sweating  and  red- 
ness were  relieved.  This  procedure,  indeed,  had  been  recommended  by 
Huf eland  as  far  back  as  1839.  Engelhorn  never  withdraws  more  than  100 
c.cm.  of  blood  at  one  time,  although  in  a  few  cases  it  was  necessary  to  repeat 
the  venesection. 

Local  Symptoms. —  The  most  frecjuent  of  the  local  symptoms  of  the 
menopause  is  the  so-called  senile  vulvovaginitis,  characterized  especially  by 
a  troublesome  leucorrhea,  sometimes  slight  hemorrhage,  and  frequently 
pruritus  vulvae.  The  latter  may  be  noted  even  when  there  is  no  local 
alteration  in  the  vulvovaginal  mucosa.  It  is  often  a  most  annoying  and 
perhaps  agonizing  symptom.  It  need  scarcely  be  said  that  when  pruritus  is 
due  to  some  local  cause,  whether  this  be  vulvovaginitis,  eczema,  pediculi 
pubis,  etc.,  the  local  condition  must  receive  direct  treatment.  If  it  can  be 
cured,  the  pruritus  will  usually  disappear  unless  extensive  tissue  changes 
have  been  produced.     In  the  latter  case,  it  may  persist. 

Special  emphasis  must  be  laid  upon  the  importance  of  careful  examination 
of  the  urine,  particularly  for  the  presence  of  sugar.  More  than  once  in  my 
experience  a  persistent  pruritus  has  thus  led  to  the  diagnosis  of  a  previously 
unsuspected  diabetes. 

In  the  so-called  neurotic  cases,  however,  no  local  cause  can  be  discovered. 
Relief  of  the  symptoms  is  often  an  extremely  difficult  matter,  as  one  may 
judge  from  the  number  of  remedies  which  have  been  suggested.  One  of 
the  simplest  and  best,  in  my  experience,  is  carbolic  acid,  applied  as  a  lotion 
in  the  strength  of  from  two  to  five  per  cent.  It  may  be  combined  with  a 
little  glycerin  or  alcohol,  or  it  may  be  applied  as  an  ointment. 

The  following  prescriptions  are  suggested  by  Kelly : 

I^      Pulv.  camph gr.  iv 

Menthol gr.  x 

Ac.  carbolic gr.  xxv 

Lanolin §  i 

M.  S.         Apply  externally. 

19     Cocain  hydrochl'orid gr.  vi 

Lanolin o  i 

M.  S.         Apply  externally. 

I^     Liq.  plumb,  subacetat 5  ii 

Tinct.  opii 3  ii 

Liq.  calcis 5  vi 

M.  S.         Apply  externally. 

Finally,  mention  must  be  made  of  the  efficacy  in  the  treatment  of  these 
cases  of  the  powerful  new  therapeutic  agent,  radium.     Many  cases  which 


142  MENSTRUATION  AND  ITS  DISORDERS 

have  resisted  other  forms  of  treatment  are  promptly  cured  by  one  or  two 
apphcations  of  radium. 

Organotherapy. —  This  subject  is  fully  discussed  in  Chapter  XXVI. 

XIII 
LITERATURE 

Bloom.     Physiological  and  Surgical  Menopause  Compared.     Univ.  M.  Mag. 

(Phila.)  1895-6,8,342. 
BoRNER.     Cyclopaedia  of  Obstetrics  and  Gynecology.     New  York,  1887,  11. 
Craig.     The  Menopause.     Jour.  A.  M.  A.,  1908,  51,  1507. 
CuLBERTSON.     The  Menopause,  with  Special  Reference  to  Vasomotor  Disturb- 
ances.    Surg.  Gyn.  and  Obst.,  1916,  23,  667. 
Currier.     The  Menopause.     1897. 
CzEMPiN.     Pathologic   und   Therapie  des   Klimakteriums.     Zeitsch.    f.   Arztl. 

Fortbild.  (Jena)  1908,  5,  746. 
Dubois.     Zur  Frage  der  Sogenannten  Ausfallserscheinungen.     Monats.  f.  Geb. 

u.  Gyn.,  1913,  yj,  206. 
Engelhorn.     Zur    Behandlung    der    Ausfallserscheinungen.     Miinch.    Med. 

Wochensch.,  1915,  62,  1527. 
Fraenkel,     Meine  Ersten  28  Fallen  Giinstigen  Beeinflussung  von  Perioden- 

beschwerden.     Zentralb.  f.  Gyn.,  1908,  32,  142. 
Gallant.     Delayed  Menopause ;  its  Dangers  and  Therapeutic  Indications,  etc. 

New  York  M.  J.,  1910,  91,  1282. 
Giles.     The  Menopause,  Natural  and  Artificial.     Lancet,  1910,  i,  430. 
Herz.     Kropfherz,  Myomherz,  Klimakterium.     Wien.  Med.  Wchnsch.,  1913, 

63,  1355- 
Johnstone.     The  Menopause,  Natural  and  Artificial.     N.  Y.  Jour.  Gyn.  and 

Obst.,  1894,  4,  393. 
KiscH.     Das  Klimakterische  Alter  der  Frauen  in  Physiologischen  und  Patho- 

logischen  Beziehung.     Erlangen,  1874. 
Die  Herzbeschwerden  Klimakterischen  Frauen.    Berl.  Klin,  Wochensch., 

1889,  26,  1087. 
Maranon.      La  edad  critica.      Madrid,  1919  (abst.  Inter,  abst.  Surg.,  1920, 

March,  p.  204) . 
Moll.     Untersuchungen  fiber  die  Libido  Sexualis.     Berlin,  1898. 
Neumann.     Ueber  Postklimakterische  Genitalblutungen.     Monats.  f.  Geb.  un. 

Gyn.,  1895,  I,  238. 
NoRRis.     The  Menopause ;   an  Analysis  of  200  Cases.     Amer.  J.  Obst.,  1910, 

61,  2030. 
Sanes.     Statistical  Study  of  Age  of  Menopause.     Trans.  Sect,  Obst.,  Gyn.  and 

Abd.  Surg.  A.  M.  A.,  1918,  p,  258, 

■ Vertigo  of  Menopause.     Amer,  J,  Obst.,  1919,  79,  7, 

Stark.     Premature  Menopause.     Am.  J.  Obst,  1910,  61,  664.     Also  in  Surg. 

Gyn.  and  Obst.,  1910,  10,  38. 
Tilt.     The  Change  of  Life  in  Health  and  Disease.     Phila.,  1883. 
Williams.     Cardiopathies  of  the  Menopause.     Clin.  J.  London,   1908-9,  33, 

325- 


CHAPTER  XIV 

THE  HYGIENE  OF  THE  MENOPAUSE 

General  Measures. —  Other  things  being  equal,  the  woman  who  ap- 
proaches the  chmacterium  in  good  physical  health  is  much  less  likely  to 
suffer  severe  disturbances  than  the  one  who  arrives  at  this  period  worn  out 
by  physical  disease,  many  childbirths,  domestic  cares  and  anxieties,  and  other 
such  causes.  It  seems  scarcely  necessary,  therefore,  to  emphasize  the 
importance  at  this  epoch  of  such  factors  as  fresh  air,  plenty  of  rest,  proper 
regulation  of  the  bowels,  etc.  Sociologic  considerations  may  make  it  im- 
possible to  secure  all  these  desiderata  in  full  measure,  but  the  ideal  should 
be  approximated  as  closely  as  possible. 

Of  especial  importance  is  the  avoidance  of  worry  and  anxiety.  The 
brunt  of  the  menopausal  storm  seems  to  fall  upon  the  woman's  nervous 
system,  and  this  should  be  spared  in  every  possible  way.  Members  of  her 
family  should  be  urged  to  show  her  every  consideration  at  this  trying  period, 
when  even  pronounced  temperamental  changes  may  make  themselves  evi- 
dent. Owing  to  the  instability  of  the  nervous  system  at  this  period,  influ- 
ences which  at  other  times  would  be  without  effect  may  at  the  menopause 
result  in  more  or  less  troublesome  psychopathies.  This  is  especially  true  in 
the  case  of  women  with  a  neurotic  taint  (Chapter  XV). 

The  Education  of  Women  as  to  the  Danger  of  Cancer. —  By  far  the 
greatest  danger  to  be  feared  at  or  near  the  time  of  the  menopause  is  the 
development  of  cancer  of  the  uterus.  The  most  important  hygienic  consid- 
eration at  the  climacterium,  therefore,  is  the  education  of  women  as  to  the 
danger  signals  of  this  dread  disease.  Foremost  in  importance  among  these 
is  uterine  bleeding,  which  is  the  initial  symptom  in  the  largest  number  of 
cases.  Even  when,  as  sometimes  happens,  its  appearance  is  preceded  by 
that  of  a  watery  leucorrhea,  it  is  the  abnormal  bleeding  which  is  most  likely 
to  direct  the  woman's  attention  to  the  possibility  of  serious  trouble. 

Unfortunately,  there  is  prevalent  among  women  a  belief  that  menstrual 
excess  is  often  a  concomitant  of  the  normal  menopause,  and  hence  this 
symptom  is  frequently  disregarded  until  the  disease  has  reached  a  hopeless 
stage.  In  other  cases,  again,  even  though  the  woman  herself  be  sufficiently 
enlightened  to  suspect  the  development  of  uterine  cancer,  the  dread  of 
having  this  suspicion  confirmed  deters  her  from  seeking  medical  advice. 

For  this  reason,  I  have  always  felt  that  in  all  cancer  educational  work, 
whether  carried  on  with  individual  women  by  individual  physicians,  or  on 
a  large  scale  by  organizations  devoted  to  the  purpose,  emphasis  should  be 

143 


144  MENSTRUATION  AND  ITS  DISORDERS 

laid  upon  the  fact  that  cancer  is  by  no  means  the  only  cause  of  menopausal 
bleeding,  and  that  most  of  the  other  causes  offer  far  more  encouraging 
prospects  of  cure  than  cancer.  Furthermore,  it  should  be  urged  that  even 
when  cancer  is  present,  it  is  often  curable  in  its  early  stages,  and  that  certain 
cases  of  cancer,  i.  e.,  carcinoma  of  the  fundus,  are  often  amenable  to  cure 
even  when  they  have  been  present  a  relatively  long  time.  In  other  words, 
the  message  should  be  one  of  hope  and  encouragement  rather  than  one  of 
despair,  so  that  women  may  come  to  feel  that  there  is  a  vitally  important 
incentive  for  watchfulness  at  this  period. 

The  Responsibility  of  the  Physician. — ■  Not  always,  however,  is  the 
patient  herself  responsible  for  the  fatal  delay  in  the  recognition  of  uterine 
cancer.  In  spite  of  the  fact  that  the  ominous  significance  of  climacteric 
bleeding  has  been  repeatedly  emphasized  by  innumerable  authors,  it  is  unfor- 
tunately true  that  not  infrequently,  even  in  this  day,  it  is  the  physician  who 
is  to  blame  for  disregarding  this  symptom  when  it  is  reported  to  him  by  the 
patient.  The  proper  attitude  of  the  practitioner  toward  suspicious  meno^ 
pausal  hemorrhage  is  so  well  expressed  by  Thornton  that  I  cannot  do  better 
than  to  quote  him  verbatim,  as  Cullen  has  done : 

"  How  is  an  early  diagnosis  to  be  made?  Clearly,  by  neglecting  no  men- 
strual departure  from  the  normal,  however  trivial  it  may  at  first  sight 
appear,  but  encouraging  the  patient  to  at  once  accurately  describe  symptoms, 
and  above  all  insisting  in  the  most  determined  manner  on  a  local  examina- 
tion. Here  it  will  be  apparent  that  I,  as  a  consultant,  appeal  for  help  to  the 
great  body  of  those  who  are  now  listening  to  my  remarks,  to  my  profes- 
sional brethren  engaged  in  general  practice.  I,  in  common  with  those 
situated  as  I  am,  too  seldom  have  an  opportunity  of  diagnosing  early, 
because  the  majority  of  the  patients  come  to  us  too  late,  when  the  disease 
had  already  advanced  nearly,  or  quite,  beyond  the  limits  of  surgical  aid. 
Let  me  then  appeal  to  all  engaged  in  family  practice  who  listen  to  me  here, 
and  to  that  larger  body  who  may  read  my  words  when  reproduced  in  the 
medical  journals,  to  sternly  cast  aside  that  too  great  modesty,  or  that 
tendency  to  treat  as  trivial  small  symptoms,  and  to  at  once  take  alarm  about, 
and  carefully  investigate,  every  case  in  which  there  is  brought  to  their 
notice  an  abnormality  in  menstruation,  or  a  vaginal  discharge  of  any  kind, 
however  trifling.  A  very  grave  responsibility  lies  at  the  doors  of  the 
medical  profession  for  the  small  progress  made  in  the  early  diagnosis  of 
uterine  cancer  and  its  successful  treatment.  Hov/  constantly  is  the  con- 
sultant told :  *  I  mentioned  it  to  my  doctor  weeks  or  months  ago,  but  he 
said  "Oh,  it  is  nothing;  I  will  send  ;^ou  a  little  medicine  or  a  little  injec- 
tion," and  never  even  suggested  any  internal  examination,  so  I  did  not  like 
to  trouble  him  again  until  the  pain  became  so  bad  or  the  discharge  sO'  trou-. 
blesome,  and  then  he  examined  me  and  said  I  must  have  special  advice  at 
once.'  Invaluable  weeks  or  months  gone,  and  then  the  verdict  of  the  con- 
sultant, *  It  is  not  a  case  for  operation,'  which  really  means  *  You  have  come 
too  late,'  but  cannot  be  so  candidly  expressed,  because  he  must  guard  the 


THE  HYGIENE  OF  THE  MENOPAUSE  145 

reputation  of  his  professional  brother.  I  admit  that  the  false  modesty  of 
the  patient,  especially  in  some  classes  of  society,  makes  the  position  a  diffi- 
cult one,  especially  for  the  young  family  doctor,  but  let  me  implore  you  all 
to  wake  to  what  is  at  stake,  and  to  be  firm  in  your  demand  for  an  examina- 
tion, and  if  you  have  any  doubt  after  such  an  examination,  to  urge  that  the 
patient  should  at  once  seek  the  advice  of  some  one  who  has  larger  oppor- 
tunities than  yourself  for  forming  a  sound  opinion.  I  will  go  one  step 
further,  and  ask  you,  if  there  should  be  any  to  whom  such  a  temptation 
comes,  never  to  go  on  treating  a  case  in  which  there  is  a  shadow  of  doubt, 
either  because  you  doubt  or  because  you  want  practice;  if  the  case  is  sus- 
ceptible of  treatment  at  all,  it  is  only  surgical  treatment  which  can  avail, 
and  that  of  so  severe  a  kind  that  it  requires  the  knowledge  of  the  specialist, 
if  ever  any  disease  did  or  does  require  special  knowledge  and  special  skill 
in  operative  treatment." 

XIV 

LITERATURE 

CuLLEN.     Cancer  of  the  Uterus.     1900. 

Craig.     The  Menopause.     Jour.  A.  M.  A.,  1908,  51,  1507. 

Currier.     The  Menopause.     1897. 

Kelly.     Medical  Gynecology.     New  York,  1908. 

KiscH.     The  Sexual  Life  of  Woman  in  its  Physiological,  Pathological,  and 

Hygienic  Aspects.     Trans,  by  M.  E.  Paul,  1910. 
Stark.     Climacteric  Hemorrhage.     Surg.,  Gyn.  and  Obst.,  1910,  10,  38. 
Thornton.     The  Early  Diagnosis  of  Malignant  Disease  of  the  Uterus,  etc, 

Brit.  M.  J.,  1896,  I,  261. 


CHAPTER  XV 
PSYCHOPATHIES  OF  THE  MENOPAUSE 

Incidence. —  The  various  psychoses  of  the  menopause  constitute  an 
important  group  of  cases.  I  have  been  unable  to  find  a  statistical  study  of 
this  subject  upon  any  large  number  of  cases  in  this  country.  In  England, 
however,  a  thorough  investigation  of  the  menopausal  psychoses  has  been 
made  by  R.  Percy  Smith,  who  presented  his  results  at  the  meeting  of  the 
Section  of  Neurology  and  Psychological  Medicine  of  the  British  Medical 
Association  in  19 12. 

According  to  Smith,  the  statistical  tables  of  the  Lunacy  Commissions  for 
England  and  Wales  state  that  the  climacteric  is  a  cause  or  an  associated 
factor  in  8.2  per  cent  of  all  the  cases  of  female  patients  admitted  to  public 
and  private  asylums  and  registered  hospitals  in  the  years  1907,  1908  and 
1909.  It  is  shown  that  mental  disorder  at  the  climacteric  occurs  more  fre- 
quently in  private  patients  than  in  those  of  the  pauper  class,  the  figures  for 
the  former  being  11.2  per  cent  of  admissions  and  for  the  latter  7.8  per  cent. 
This  Smith  explains  by  the  fact  that  with  the  former  class  such  factors  enter 
as  idleness,  introspectiveness,  etc. 

In  1 87 1  cases  of  insanity  in  women  which  came  under  Smith's  personal 
observation  at  Bethlehem  Hospital,  the  number  of  cases  in  which  the 
menopause  was  considered  to  be  a  cause  or  an  associated  factor  was  118, 
or  6.3  per  cent.  Baugh's  figures,  based  on  510  female  patients  admitted  to 
the  Gartloch  Mental  Hospital  for  Glasgow,  during  a  period  of  four  years, 
indicate  that  only  3.1  per  cent  of  the  total  admissions  were  to  be  classed  as 
climacteric  insanity. 

Influence  of  the  Marital  State. — In  219  cases  of  climacteric  insanity 
studied  by  Smith  at  the  Bethlehem  Hospital,  and  in  private  practice,  34.5 
per  cent  were  single  women.  Of  102  cases  studied  by  Goodall  42.1  per  cent 
occurred  in  single  women,  while  Craig  found  that  21.5  per  cent  of  120 
patients  with  climacteric  insanity  were  single.  From  these  figures  it  might 
appear  that  the  psychoses  affect  married  women  much  more  frequently  than 
the  unmarried.  Allowance  must  be  made,  however,  for  the  much  greater 
number  of  married  than  of  unmarried  women  in  the  population  at  the 
climacteric  age.  Thus,  as  Smith  points  out,  in  England  there  is  only  one 
single  woman  to  about  six  married  women  or  widows  in  the  decade  from  45 
to  54  years,  so  that  the  actual  incidence  of  climacteric  insanity  is  really 
greater  in  single  women  than  in  the  married. 

Age  of  Patients. —  Menopausal  insanity  may  obviously  occur  at  any 

146 


PSYCHOPATHIES  OF  THE  MENOPAUSE  147 

age  at  which  the  menopause  occurs.  Extremes  of  38  and  61  years  are 
mentioned  by  Smith.  The  average  ages  at  which  cHmacteric  insanity  was 
noted  by  Smith,  Goodall,  and  Craig  were  48.9,  46.7  and  47.5  respectively. 

Influence  of  Heredity. —  In  loi  private  cases  Smith  found  a  family  his- 
tory of  insanity,  neuroses,  alcohohsm,  and  drug  habits  in  58  per  cent.  In 
addition,  in  6  cases  a  child  of  the  patient  had  previously  broken  down  men- 
tally, or  had  been  congenitally  imbecile.  These  figures  indicate  that  in  a 
large  proportion  of  cases  the  menopausal  crisis  acts  simply  as  the  exciting 
cause  of  insanity  in  patients  who  already  are  strongly  predisposed  to  it. 

The  figures  of  Smith,  it  must  be  repeated,  are  based  on  private  cases 
alone,  and  the  greater  ease  with  which  adequate  histories  can  be  obtained 
in  such  cases  may  explain  the  rather  startling  percentage  of  cases  in  which 
heredity  plays  an  influential  factor.  A  similar  study  of  pauper  cases,  made 
from  figures  of  the  Lunacy  Commissions  for  England  and  Wales,  shows 
that  in  only  29  per  cent  was  there  obtained  a  history  of  heredity  in  insanity, 
epilepsy,  neuroses  or  alcoholism. 

Correlated  Causes. —  The  tables  just  quoted  further  indicate  that  in 
39  per  cent  of  the  cases  of  menopausal  insanity,  the  climacteric  alone  was 
given  as  a  cause.  In  19  per  cent  sudden  or  prolonged  mental  stress  was 
given  as  a  contributing  cause,  while  in  J. 6  per  cent  alcoholism  was  given  as 
a  causative  factor. 

Previous  Attacks. —  In  a  review  of  118  cases  from  the  Bethlehem  Hos- 
pital, Smith  found  that  41,  or  34.7  per  cent,  had  suffered  with  previous 
attacks  of  mental  disorder.  In  10 1  private  cases,  the  percentage  was  33. 
These  figures  indicate  that  climacteric  insanity  is  not  to  be  looked  upon  as  a 
special  form  of  insanity,  but  that  the  climacterium,  like  any  other  crisis, 
merely  breaks  down  the  resistance  of  an  unstable  mind.  This  view  is 
supported  by  no  less  an  authority  than  Krapelin. 

Types  of  Mental  Disorders. —  The  manifestations  of  climateric  in- 
sanity are  quite  protean.  As  Sir  George  Savage  remarks,  "  any  normal 
symptom,  bodily  or  mental,  which  may  occur  with  the  menopause,  may  be 
so  exaggerated  as  to  become  morbid."  The  psychic  disorders  especially  are 
numerous  and  varied.  Not  infrequently  they  are  strongly  sexual  in 
character. 

Sir  Felix  Semon  lays  stress  on  the  frequency  with  which  sensory  neuroses 
of  the  throat  are  noted  at  this  period.  They  are  never  of  the  anesthetic  type, 
paresthesia  or  neuralgia  being  the  usual  manifestations.  They  may  either 
precede  or  be  associated  with  the  menstrual  irregularities  of  the  menopause. 
Sensations  of  constriction  in  the  throat,  or  a  feeling  that  the  food  stops  in 
the  throat,  are  quite  common. 

The  prodromal  symptoms  are  summed  up  by  Goodall  and  Craig  as  fol- 
lows :  "  Insomnia,  alterations  in  temper,  neurosis,  noises  in  the  head  and 
ears,  and  deafness,  hallucinations  of  the  various  senses;  suspicions,  jeal- 
ousies, false  accusations;  failure  of  attention,  impairment  of  memory;  sexual 
perversions  (erotism,  frigidity,  masturbation,  etc.)." 


148  MENSTRUATION  AND  ITS  DISORDERS 

The  depressed  or  melancholic  forms  of  insanity  are  the  most  frequent 
at  the  menopause.  Not  infrequently  they  assume  a  suicidal  tendency.  Of 
219  cases,  Smith  found  that  66  per  cent  were  classed  as  melancholia.  Any 
or  all  of  the  usual  manifestations  of  the  latter  may  be  observed  —  the  depres- 
sion and  lack  of  energy,  inability  to  concentrate  thought  or  attention, 
insomnia,  feeling  of  worthlessness,  headache,  desire  for  death,  etc. 

Maniacal  insanity  is  much  less  common,  but  may  occur.  Paranoia  was 
found  by  Goodall  and  Craig  in  9.8  per  cent  of  the  cases  at  the  Bethlehem 
Hospital,  in  14.  i  per  cent  at  Wakefield.  Smith  found  it  in  about  16  per  cent 
of  his  cases.  A  large  number  of  the  delusional  cases  have  a  strongly  sexual 
basis. 

Illustrative  Cases. —  A  very  brief  sketch  of  a  few  personal  cases  will 
illustrate  some  of  the  types  assumed  by  climacteric  insanity : — 

1.  A  woman  of  48,  unmarried,  was  convinced  she  was  pregnant  because 
she  had  had  one  coitus  many  years  before.  Nothing  could  shake  her  con- 
viction, even  after  a  myomatous  uterus,  about  the  size  of  a  small  cocoanut, 
had  been  removed. 

2.  A  woman  of  44,  who  had  recently  passed  through  a  severe  attack  of 
typhoid  fever,  and  who  had  previously  exhibited  signs  of  beginning  meno- 
pausal mental  disorder,  believed  that  enemies  were  endeavoring  to  steal 
her  two  children,  whom  she  therefore  kept  under  constant  watch.  She 
could  hear  her  supposed  persecutors  plotting  under  her  window  at  night. 

3.  A  woman  of  49,  a  widow,  who  had  hitherto  been  temperate  in  her 
religious  beliefs  and  practices,  became  quite  maniacal.  Hour  after  hour  of 
day  and  night  was  spent  in  loud  prayers  before  images  of  the  saints. 

Smith  mentions  the  following  cases,  among  a  number  of  others : — 

1.  A  woman  of  49,  with  the  delusion  that  she  smells,  and  is  decaying, 
and  is  rotten  with  syphilis,  asks  her  husband  to  shoot  her.  Committed 
suicide  by  hanging. 

2.  A  married  woman  of  46,  who  developed  the  delusion  that  her  husband 
was  poisoning  her  "  per  vaginam  "  during  intercourse,  that  he  was  unfaith- 
ful to  her,  and  would  kill  her,  and  that  her  daughter  was  immoral.  This 
was  associated  with  eroticism,  the  patient  stripping  herself  and  demanding 
sexual  intercourse. 

Prognosis. —  Roughly  speaking,  it  may  be  said  that  something  like 
one  half  the  cases  recover.  Clouston  found  the  proportion  to  be  57  per  cent 
in  228  cases,  but  Goodall  and  Craig  give  it  as  35.29  per  cent  in  the  cases  at 
the  Bethlehem  Hospital,  and  40.8  per  cent  at  Wakefield.  Smith's  cases  give 
a  percentage  of  42.3  per  cent  of  recoveries.  It  is  scarcely  necessary  to  say 
that  tlie  prognosis  depends  in  large  measure  upon  the  type  of  mental  disorder 
which  attacks  the  patient.     The  paranoiac  cases,  of  course,  l^ecome  chronic. 


PSYCHOPATHIES  OF  THE  MENOPAUSE  149 

XV 
LITERATURE 

Baugh.     Vera  and  Praesenilis  Melancholia  at  the  Climacteric.     Brit.  M.  J., 

1908,  2,  826. 
Paranoidal  Symptoms  at  the  Female  Climacteric.     Brit.  M.  J.,  1910,  2, 

1244. 
Berger.     Ueber  die  Psychosen  des  Klimacteriums.     Monats.  f.  Psychiat.  u. 

Neurol,  1907,  22,  13. 
Bossi.     Eierstocks-Uteruskrankheiten  und  Psychopathien.     Beitr.  z.  Geb.  u. 

Gyn.,  1913,  18,  136. 
Clouston.     Climacteric  Insanity.     Allbutt's  System  of  Medicine,  v.  8. 
CONKLIN.     Climacteric  Insanity.     Am.  J.  Med.  Sci.,  1871,  62,  365. 
Eliot.     The  Disorders  of  the  Nervous  System  Associated  with  the  Change  of 

Life.     Amer.  J.  Med.  Sc,  1893,  106,  292. 
GooDALL  AND  Craig.     The  Insanity  of  the  Climacteric  Period.     Jour,  of  Ment. 

Sc,  1894,  40,  235. 
Krapelin.     Psychiatric.     4  aufl.  Leipz.,  1893. 
RoHE.     Mental  Disturbances  of  Climacteric  Period.     Maryland  M.  J.,   1895, 

34,  258. 
Ross.     Menstruation  and  Insanity.     J.  Ment.  Sc,  1909,  55,  270. 
Savage.     Some  Mental  Disorders  Associated  with  the  Menopause.     Lancet, 

1893,2,1128. 
Semon.     The  Sensory  Throat  Neuroses  of  the  Climacteric  Period.     Brit.  M. 

J.,  1895,  I,  3. 
Smith,  Macalister,  and  Grimsdale.     Psychoses  of  Climacteric.     Brit.  M.  J., 

1912,  2,  1378. 
SoROKiNA.     Ueber  die  Psychose  des  Klimakteriums.     Bern.,  1910. 


CHAPTER  XVI 

RELATION  OF  MENSTRUATION  AND  OVULATION 

Historical. —  Ever  since  the  discovery  of  the  human  ovum  by  von 
Baer  in  1827  there  has  been  much  discussion  as  to  the  relation,  if  any,  which 
exists  between  the  phenomena  of  menstruation  and  ovulation.  The  older 
writers  appear  to  have  assumed  quite  g-enerally  that  the  menstrual  bleeding 
is  the  result  of  the  general  pelvic  congestion  believed  to  accompany  the 
ripening  of  the  follicle  and  the  escape  of  the  ovum.  I  believe  that  it  was 
Matthews  Duncan  who  stated  that  the  menstrual  flow  might  be  compared  tO' 
the  red  flag  hung  outside  the  door  of  an  auction  room,  showing  that  some- 
thing is  going  on  inside. 

As  we  have  already  seen^  the  earlier  writers,  like  Freind  and  Astruc, 
believed  that  menstruation  is  induced  by  ovulation,  and  that  in  the  event 
of  fertilization  of  the  ovum,  the  menstrual  blood  is  retained  for  the  nourish- 
ment of  the  embryo.  The  occurrence  of  graafiian  follicles  had  been 
described  by  de  Graaf,  after  whom  they  were  named,  as  early  as  1665.  It 
was  not  until  1839,  however,  that  Gendrin  asserted  the  dependence  of  men- 
struation upon  spontaneous  ovulation.  Negrier,  in  183 1,  and  Lee,  of 
London,  in  the  same  year,  are  said  to  have  already  described  the  interrela- 
tionship of  these  two  phenomena,  Brierre  de  Boismont,  Bischoff,  and 
Pouchet  all  believed  in  the  dependence  of  menstruation  upon  follicular 
rupture,  i.  e.,  upon  ovulation. 

This  same  relationship  was  assumed  in  the  well  known  theory  of  Pfliiger, 
which  was  published  in  1865,  and  which  enjoyed  quite  general  acceptance, 
virtually  up  to  the  beginning  of  the  present  century.  According  to  this 
theory  the  stimulus  for  the  menstrual  congestion  is  excited  reflexly 
through  the  medium  of  nerve  channels  by  the  ripening  of  the  follicle.  The 
rupture  of  the  follicle  with  the  discharge  of  its  ovum  was  considered  to  take 
place  during  or  just  after  the  menstrual  bleeding.  Somewhat  similar  views 
were  entertained  by  Leopold  and  his  pupils,  Mironoff  and  Ravano. 

Relation  of  Estrus  and  Ovulation  in  Lower  Animals. —  Not  a  great 
deal  of  light  has  been  thrown  upon  this  question,  as  it  concerns  human 
beings,  by  a  study  of  estrus  and  ovulation  in  the  lower  animals.  Most  of 
our  knowledge  concerning  these  matters  has  beep  gained  from  investiga- 
tions upon  domesticated  animals  or  upon,  wild  animals  in  a  state  of  cap- 
tivity. The  studies  of  Heape  and  others  seem  to  show  that  in  the  lower 
animals,  at  any  rate,  ovulation  is  not  necessarily  coincident  with  estrus.  On 
examining  the  pelves  of  forty-two  monkeys  during  estrus,  Heape  found 

150 


RELATION  OF  MENSTRUATION  AND  OVULATION  151 

evidence  of  ovulation  in  only  two.  In  the  same  way,  histological  examina- 
tion of  the  ovaries  of  bats  at  the  time  of  estrus  shows  that  they  are  fallow, 
and  that  ova  do  not  ripen  until  several  months  afterward,  the  spermatozoa 
being  carried  into  the  genital  tract  during  the  intervening  period. 

The  most  recent  experimental  work  on  this  subject  is  that  of  Marshall 
and  Runciman,  whose  investigations,  like  those  of  Heape,  indicate  that  there 
is  no  relationship  between  ovulation  and  the  estrous  cycle.  They  point  out 
that  most  animals  ovulate  after  the  pro-estrum  is  over,  so  that  corpora  lutea 
are  not  necessarily  found  when  "  heat  "  begins.  Furthermore,  they  call 
attention  to  the  fact  that  in  the  cat,  the  rabbit,  and  certain  other  animals, 
ovulation  takes  place  ordinarily  only  after  sexual  intercourse.  Corpora 
lutea  are  not  found,  therefore,  in  the  absence  of  the  male,  and  yet  the  female 
rabbit  and  cat  may,  in  this  condition,  experience  recurrent  periods  of 
"  heat." 

The  studies  of  Marshall  and  Runciman  were  made  upon  four  bitches. 
The  dates  of  periodic  sexual  activity  w^ere  determined  by  a  period  of  pre- 
liminary observation.  The  effect  of  ovulation,  or  rather  of  its  non-occur- 
rence, upon  the  expected  recurrence  of  estrus  was  determined  by  rupturing 
all  the  visible  follicles  in  both  ovaries  at  definite  periods  preceding  estrus. 
The  experiments  indicated  that  "  the  occurrence  of  heat  in  dogs  does  not 
depend  upon  the  presence  of  mature  (or  nearly  mature)  graafian  follicles 
in  the  ovaries.  It  is  equally  evident  that  it  is  not  dependent  upon  corpora 
lutea.  It  must  be  supposed,  therefore,  that  the  ovarian  factor  in  the  recur- 
rence of  "  heat "  resides  in  some  other  ovarian  element  or  combination  of 
elements.  The  ovarian  interstitial  cells  are  possibly  concerned  in  the 
process,  but  cyclical  changes  in  the  condition  of  these  cells  have  not  so  far 
been  observed  in  the  dog's  ovaries.  The  view  which  has  generally  been 
maintained,  that  the  ripening  of  the  graafian  follicles  and  the  onset  of  men- 
struation or  heat  stand  to  one  another  in  the  relation  of  cause  to  effect,  must 
be  finally  abandoned.  It  is  probable  that  both  series  of  changes  are  effects 
of  some  more  deep  seated  ovarian  phenomenon." 

Although  the  results  of  Marshall  and  Runciman  are  very  suggestive,  it 
would  seem  that  the  material  on  which  the  study  is  based  is  too  meagre  to 
allow  of  any  very  emphatic  generalizations.  Their  methods,  moreover,  do 
not  seem  to  be  free  from  objection.  They  state  that  "  the  ovaries  were 
exposed,  and  each  follicle,  showing  on  the  surface,  was  pricked  by  a  knife 
or  needle."  It  would  seem  to  be  very  difficult,  by  their  method,  to  exclude 
the  possibility  that  one  or  more  follicles  may  be  left  behind  or  may  develop 
and  ovulate  subsequently  to  the  operation. 

Attention  may  again  be  called  to  the  studies  of  Fraenkel,  Loeb,  Halban, 
and  others,  which  have  already  been  described  at  some  length  in  a  preceding 
chapter  (Chapter  VII).  It  will  be  recalled  that  the  results  obtained  by 
these  various  investigators  were  so  unlike  that  they  permit  of  no  definite 
conclusions,  on  experimental  grounds,  as  to  the  exact  relation  between 
menstruation  and  ovulation. 


152  MENSTRUATION  AND  ITS  DISORDERS 

CLINICAL  OBSERVATIONS  ON  RELATION  OF  MEN- 
STRUATION AND  OVULATION 

General  Considerations. —  The  numerous  clinical  reports  which  have 
been  made  on  this  subject  throw  even  less  light  on  it  than  do  the  experi- 
mental studies  which  have  been  made.  The  contradictory  nature  of  these 
observations  is  in  large  measure  due  to  the  unreliability  of  the  evidence  as 
to  the  exact  date  of  ovulation.  For  example,  the  mere  presence  of  a  corpus 
luteum  in  the  ovary  cannot,  as  has  so  frequently  been  assumed,  be  looked 
upon  as  indicating  that  ovulation  has  occurred  just  previously.  Again, 
many  authors  have  confused  the  problem  of  whether  menstruation  is  caused 
by  ovulation  with  the  totally  different  question  of  whether  or  not  these  two 
phenomena  occur  synchronously. 

Many  of  the  observations  bearing  on  these  problems  are  rendered  quite 
valueless  by  such  considerations  as  these.  At  the  present  time  it  cannot 
be  said  that  clinical  investigations  have  offered  conclusive  evidence  either 
for  or  against  the  theory  that  there  is  a  definite  relationship  between  the 
functions  of  ovulation  and  menstruation.  Many  suggestive  facts  have  been 
brought  out  in  this  connection,  however,  which  when  taken  together  with 
the  results  of  histological  and  experimental  studies,  have  thrown  much  light 
on  this  important  problem.  It  may  be  of  interest  to  review  some  of  the 
more  important  observations  which  seem  to  bear  on  this  question. 

Ovulation  Before  Puberty. —  Numerous  cases  are  recorded  in  which 
ovulation,  demonstrated  by  pregnancy,  has  occurred  before  the  onset  of  the 
menstrual  function.  It  is  said  that  among  some  savage  tribes  it  is  consid- 
ered a  crime  for  a  girl  to  menstruate  before  she  is  married,  such  marriages 
often  resulting  in  pregnancy  before  the  onset  of  the  menstrual  function. 

The  occurrence  of  pregnancy  in  a  woman  of  thirty-two  who  had  never 
menstruated  is  reported  by  Ahlfeld.  The  same  author  reports  a  case  of 
extra-uterine  pregnancy  in  a  girl  of  thirteen  who  had  never  menstruated. 
De  Sinety  reports  the  case  of  a  woman  of  thirty-eight  who  had  never  men- 
struated, although  the  ovaries  were  normal.  Graafian  follicles  were  pres- 
ent, as  well  as  corpora  lutea,  showing  that  ovulation  had  occurred.  As  a 
matter  of  fact,  corpora  albicantia  and  a  corpus  luteum  were  found  by  Runge 
in  the  ovary  of  a  newborn  child. 

Ovulation  During  "  Dodging  Period  "  of  Puberty  and  Menopause. — 
There  are  few  physicians  who  have  not  noted  the  occurrence  of  pregnancy 
during  the  "  dodging  period  "  of  either  puberty  or  the  menopause.  The 
physiological  amenorrhea  so  frequently  observed  at  these  periods  is  not 
always  easy  to  distinguish  from  the  amenorrhea  of  pregnancy.  Many  deli- 
cate and  perplexing  problems  are  thus  presented  to  the  physician.  They  are 
rendered  more  difficult  by  the  averseness  of  most  of  us  to  recommend  pelvic 
examination  in  the  case  of  young  girls,  and,  on  the  other  hand,  by  the  per- 
fection with  which  at  least  the  subjective  symptoms  of  pregnancy  may  be 


RELATION  OF  MENSTRUATION  AND  OVULATION  153 

mimicked  in  the  cases  of  pseudocyesis  so  frequently  observed  at  the  age  of 
the  menopause. 

Ovulation  After  Menopause. —  Cases  are  occasionally  observed  in 
which  pregnancy  occurs  after  the  menopause.  As  a  rule  the  impregnation 
in  these  cases  occurs  within  a  year  of  the  last  observed  menstrual  period,  but 
occasionally  a  period  of  years  may  elapse  between  the  cessation  of  menstrua- 
tion and  the  occurrence  of  pregnancy. 

A  rather  remarkable  case  of  this  kind  is  that  reported  by  Buckle.  His 
patient  was  fifty  years  old,  and  had  had  seven  children,  the  last  two  (twins) 
having  been  born  fifteen  years  previously.  A  year  after  this  childbirth, 
menstruation  returned,  but  with  considerable  irregularity.  In  another  year 
it  ceased  entirely.  Eleven  years  later  she  was  delivered  of  a  boy.  Strange 
to  say,  menstruation  returned  about  a  year  after  this  childbirth,  and  had 
been  occurring  regularly  every  month  up  to  the  time  of  the  report,  when 
the  patient  had  reached  the  age  of  fifty. 

Ovulation  During  Pregnancy. —  There  has  been  some  discussion  of 
whether  or  not  ovulation  occurs  during  pregnancy,  when  amenorrhea  is,  of 
course,  the  rule.  A  satisfactory  solution  of  this  question  would  be  of  value 
in  determining  whether  ovulation  and  menstruation  go  hand  in  hand.  Un- 
fortunately the  studies  so  far  made  are  more  or  less  contradictory,  Ravano, 
Avorking  in  Leopold's  clinic,  found  that  follicles  are  continually  and  regu- 
larly undergoing  ripening  during  pregnancy,  and  that  ovulation  occurs  in 
about  5  per  cent  of  all  cases.  In  this,  however,  he  is  contradicted  by  Seitz, 
who  states  that  ovulation  never  occurs  during  pregnancy. 

Ovulation  During  Lactation. —  Another  opportunity  of  studying  the 
relation  or  lack  of  relation  between  menstruation  and  ovulation  is  afforded 
during  the  period  of  lactation.  As  is  well  known,  menstruation  is  absent 
during  lactation  in  a  large  proportion  of  women  (see  Chapter  XVII). 
Nevertheless  it  is  common  to  observe  the  occurrence  of  pregnancy  during 
this  period.  Chrobak  records  the  case  of  a  married  woman  who  did  not 
menstruate  until  after  her  fourth  childbirth. 

More  remarkable  are  the  cases  of  Roudellet  and  Joubert.  The  first  speaks 
of  a  woman  who  had  twelve  children  and  the  second  of  a  woman  who  gave 
birth  to  eighteen  children,  although  neither  had  ever  menstruated.  Meigs 
described  the  case  of  a  woman  with  ten  children,  who  had  not  menstruated 
since  marriage,  having  always  become  pregnant  before  the  return  of 
menstruation  after  confinement. 

Ovulation  During  Pathological  Amenorrhea. —  As  is  v,^ell  known 
amenorrhea  is  a  symptom  of  numierous  pathological  conditions,  especially 
those  of  a  debilitating  nature,  such  as  anemia,  tuberculosis,  lead  poisoning, 
etc.  (Chapter  XVIII).  In  spite  of  the  frequent  absence  of  menstruation 
in  such  conditions,  ovulation  and  pregnancy  not  infrequently  occur.  The 
incidence  of  pregnancy  in  women  suffering  with  pathological  amenorrhea 
is  less  than  in  normal  women,  but  this  fact  is  evidently  due  to  other  factors 
than  the  non-occurrence  of  menstruation. 


154  MENSTRUATION  AND  ITS  DISORDERS 

A  recent  case  of  my  own  is  of  interest  in  this  connection.  The  patient 
was  a  young  married  woman  of  twenty-three,  who  consulted  me  on  account 
of  amenorrhea  of  two  months  duration.  She  had  gained  twenty-five  pounds 
in  weight  in  the  preceding  few  months.  A  diagnosis  of  adiposogenital 
dystrophy  was  made,  the  uterus  being  small  and  there  being  no  evidence  of 
pregnancy.  Three  months  later  she  consulted  me  again,  not  having  men- 
struated in  the  interval.  Examination  at  this  time  showed  the  uterus  en- 
larged and  evidently  the  seat  of  a  two  months  pregnancy,  which  diagnosis 
was  confirmed  by  the  subsequent  delivery.  In  other  words,  this  woman  had 
become  pregnant  during  the  period  of  pathological  amenorrhea  associated 
with  the  adiposogenital  dystrophy. 

Evidence  from  Operative  and  Postmortem  Findings.—  Many  of  the 
older  observations  coming  under  this  head  are  more  or  less  invalidated  by 
our  newer  knowledge  of  the  life  history  of  the  graafian  follicle  and  corpus 
luteum,  so  that  they  now  possess  little  more  than  a  historic  interest.  This  is 
true,  for  example,  of  the  conclusions  arrived  at  by  Lawson  Tait  from  a  study 
of  twenty-eight  specimens  removed  by  him,  and  divided  into  three  groups. 
He  said  "  The  first  (three  cases)  show  that  menstruation  and  ovulation 
are  concurrent;  the  second  (seventeen  cases)  that  ovulation  is  certainly 
progressive  and  not  coincident  with  menstruation ;  in  the  third  (eight  cases) 
the  findings  are  doubtful.  .  .  .  The  weight  of  evidence,  however,  is 
certainly  in  favor  of  the  view  that  the  two  functions  of  ovulation  and  men- 
struation are  most  likely  quite  independent  in  the  human  female,  although 
there  are  reasons  for  believing  that  primitively,  at  any  rate,  the  most  usual 
period  for  ovulation  in  woman  was  during  a  definite  estrum  and  succeeding 
a  pro-estrum,  as  in  some  of  the  lower  animals." 

Girdwood  reported  the  case  of  a  girl  of  sixteen  who  had  menstruated  six 
times  and  in  whom  there  were  five  distinct  scars  on  the  ovaries.  He  speaks 
also  of  a  case  in  which  he  observed  thirty-five  scars  in  a  patient  who  had 
menstruated  thirty-six  times,  and  of  one  who  had  menstruated  twenty-four 
times  and  in  whom  twenty-two  scars  were  found. 

Bischofif  from  a  study  of  operative  and  postmortem  findings,  concludes 
that  the  time  relationship  between  the  bursting  of  the  follicle  and  the  occur- 
rence of  menstruation  is  subject  to  considerable  variation. 

Zinke  described  a  case  in  which  a  fully  developed  graafian  follicle  was 
found  at  the  postmortem  upon  a  woman  who  had  died  in  the  middle  of  the 
intermenstrual  period,  an  observation  more  or  less  in  accord  with  the  con- 
clusions of  recent  histological  methods  of  study,  as  will  later  be  shown. 

Hyrtl  found  an  ovum  at  the  uterine  end  of  the  fallopian  tube  in  a  woman 
who  had  died  three  days  after  menstruation. 

Leopold  and  Mironoff  reported  forty-two  cases,  in  thirty  of  which  men- 
struation and  ovulation  coincided,  while  in  the  remaining  twelve  menstrua- 
tion occurred  without  ovulation.  Arnold  collected  fifty-four  similar  obser- 
vations, in  thirty-nine  of  which  ovulation  and  menstruation  were  said  to 


RELATION  OF  MENSTRUATION  AND  OVULATION  155 

have  occurred  synchronously.     Somewhat  similar  results  have  been  reported 
by  Williams  and  by  Reichert. 

Summary  of  Clinical  Evidence. —  The  clinical  evidence  which  has 
thus  far  been  brought  forward  appears  to  prove  beyond  doubt  that  ovulation 
can  occur  without  menstruation.  It  throws  little  light,  however,  on  the 
much  more  difficult  c|uestion  of  whether  or  not  menstruation  can  occur 
without  ovulation.  It  is  easy  enough  to  determine  the  occurrence  and  the 
date  of  menstruation,  but  it  is  not  so  easy  to  determine  the  occurrence,  much 
less  the  exact  date,  of  ovulation.  It  is  this  consideration  which  makes 
difficult  the  study  of  the  relation  of  menstruation  and  ovulation,  and  espe- 
cially of  the  time  relation  between  the  two  functions.  It  is  only  by  careful 
histological  studies  of  the  ovarian  elements  at  different  periods  of  the  men- 
strual cycle  that  we  can  expect  to  arrive  at  any  intelligent  conception  of  the 
chronological  relation  between  menstruation  and  ovulation. 

HISTOLOGICAL  STUDIES  ON  RELATION  OF  OVULATION 
AND  MENSTRUATION 

General. —  By  far  the  most  valuable  and  trustworthy  evidence  as  to 
the  relation  between  these  two  phenomena  is  that  which  has  been  yielded 
by  histological  methods  of  study.  These  methods  embrace  two  principal 
lines  of  investigation,  (i)  embryological  studies,  and  (2)  histological 
studies  of  the  ovary. 

Evidence  from  Embryological  Studies. —  The  determination  of  the 
exact  time  at  which  ovulation  occurs  in  relation  to  the  menstrual  cycle  is  a 
matter  of  the  greatest  importance  to  both  obstetricians  and  embryologists. 
More  accurate  knowledge  along  this  line  would  aid  the  former  in  fixing  the 
date  of  fertilization  and  in  estimating  the  duration  of  pregnancy,  while 
embryologists,  on  the  other  hand,  would  find  a  great  difficulty  removed  in 
the  task  of  estimating  the  exact  age  of  the  fetus.  Even  when  the  date  of  a 
single  fruitful  coitus  is  known,  we  cannot  form  an  accurate  idea  of  the 
exact  time  at  which  the  ovum  was  liberated  from  the  follicle,  owing  to  the 
uncertainty  as  to  the  time  elapsing  between  ovulation  and  the  fertilization 
of  the  ovum. 

The  classic  contribution  of  Reichert  in  1868  led  to  the  acceptance  for 
many  years  of  the  theory  that  ovulation  precedes  menstruation.  His  report 
was  based  on  the  study  of  a  very  early  ovum  obtained  two  weeks  after 
menstruation  in  a  woman  who  had  committed  suicide.  A  well  developed 
corpus  luteum  was  found  in  one  ovary.  A  further  study  by  Reichert  on  the 
condition  of  the  ovaries  during  menstruation  revealed  that  in  nineteen  of 
twenty-three  cases  the  graafian  follicle  had  ruptured  at  the  beginning  of 
menstruation,  while  it  was  still  unruptured  in  the  remainder.  These  obser- 
vations, as  has  been  said,  were  the  basis  of  the  theory  that  ovulation  and 
fertilization  precede  menstruation. 

Although  the  Reichert  theory  was  accepted  by  His,  it  has  been  firmly  and 
ably  opposed  by  Mall,  whose  valuable  contributions  to  our  knowledge  of 
embryology  are  so  well  known.     He  contends  that  the  application  of  this 


156 


MENSTRUATION  AND  ITS  DISORDERS 


theory  to  the  study  of  the  very  early  ova  which  have  been  reported  yields 
very  improbable  results  as  far  as  the  estimation  of  the  ages  of  these  embryos 
is  concerned.  On  the  basis  of  the  Reichert-His  theory,  for  example,  the 
well  known  Peters  ovum,  which  was  obtained  thirty  days  after  the  last 
menstruation,  is  estimated  to  be  only  three  or  four  days  old.  The  specimen 
measured  1.6  x  0.9  mm.,  and  Mall,  from  a  comparison  of  the  rate  of  growth 
in  lower  animals,  believes  it  extremely  probable  that  the  Peters  ovum  was 
considerably  older  than  four  days  —  probably  about  fifteen.  This  view 
receives  support  from  the  fact  that  Peters'  patient  had  exhibited  morning 
sickness  before  the  missed  period. 

In  a  similar  way  Mall  analyzes  the  reports  of  other  early  ova,  arriving  at 
the  conclusion  that  most  pregnancies  take  place  during  the  first  week  after 
menstruation ;  and  that  the  duration  of  the  pregnancy  is  longer  if  copulation 
takes  place  toward  the  end  of  the  intermenstrual  period.  And  this  is  ex- 
plained, if  we  assume  that  in  the  first  week,  especially  the  first  few  days  after 
the  cessation  of  menstruation,  the  ovum  is  in  the  upper  end  of  the  tube, 
awaiting  the  sperm,  and  that  conception  immediately  follows  copulation. 
When  the  fruitful  copulation  takes  place  in  the  latter  two  weeks  of  the  month, 
the  opposite  is  usually  the  case;  the  sperm  wanders  to  the  ovary  and  there 
awaits  the  ovum,  and,  therefore,  on  an  average,  pregnancy  is  prolonged  in 
this  group  of  cases,  when  determined  from  the  time  of  copulation.  This 
explanation  fits  all  the  facts,  but  opposes  the  Reichert-His  theory. 

In  further  support  of  his  opinion  Mall  cites  the  figures  of  Ahlfeld  and 
Issmer,  based  on  a  large  series  of  cases.  Ahfeld  gives  the  following  table 
of  the  time  of  fruitful  copulation  in  relation  to  menstruation : 


ON  LAST  DAY  OF 
MENSTRUATION 

FIRST  TWELVE 

DAYS  AFTER 

BEGINNING  OF 

MENSTRUATION 

FIRST  SEVEN 
DAYS  AFTER  END  OF 
MENSTRUATION 

Married  women. . .  . 
Unmarried  women. 

35-55 
25-49 

88.44 
70.98 

88.88 
70.58 

The  figures  of  Issmer  are  as  follows : 

TIME  OF  COPULATION 

NO.  OF  CASES 

AVERAGE  DURATION  OF 
PREGNANCY 

First  week  of  menstrual  period. 
Second 
Third     "       " 
Fourth  "       •' 

172 

164 

72 

45 

277  days 
279  days 
287  days 
285  days 

RELATION  OF  MENSTRUATION  AND  OVULATION 


157 


The  preceding  tables  indicate  that  most  pregnancies  occur  during  the  first 
week  after  menstruation. 

Finally,  attention  may  be  called  to  the  work  of  Teacher,  who  made  a 
study  of  the  probable  periods  of  the  menstrual  cycle  at  which  fertilization 
and  imbedding  took  place,  based  on  an  investigation  of  twelve  selected  very 
early  ova,  including  the  famous  Teacher-Bryce  ovum.  The  following  table 
shows  the  results  obtained : 


FERTILIZATION 


DAYS  OF  MENSTRUAL  PERIOD 


IMBEDDING 


Merttens.  .  . 
Rossi  Doria 
Beneke.  .  .  . 


Eternod. 


Peters. 
Jung-  . 


Von  Spee  (Glavecke)  . 
Von  Spee  (Von  Herff), 


Frassi 

Teacher-Bryce  and  Reichert. 
Leopold 


I 

2 

3 
4 
5 
6 

7 
8 

9 

10 

II 

12 

13 
14 
15 
i6 

17 
i8 

19 

20 
21 
22 

23 

24 

2.5 
26 
27 
28 


.  .  .Merttens 
.Rossi  Doria 
Beneke 


.fiternod 


.Peters 
•  Jung 


,  .Von  Spee  (Glavecke) 
•  Von  Spee  (Von  Herfif) 


DAYS  OF  SUCCEEDING  MENSTRUAL  PERIOD 


I 

2 

3 

4 
5 
6 

Frassi 

.  .  .  .Teacher-Bryce  and  Reichert 
Leopold 

7 
8 

9 

lO 

158  MENSTRUATION  AND  ITS  DISORDERS 

This  table  shows  that,  if  the  ages  of  the  ova  be  correct,  fertiHzation  may 
occur  at  any  time  during  the  intermenstrual  interval,  and  that  imbedding 
may  take  place  either  in  the  period  of  quiescence,  or  in  the  period  when 
premenstrual  or  menstrual  changes  would  have  been  progressing,  if  preg- 
nancy had  not  occurred.  In  other  words,  Teacher  concludes  that  the  men- 
strual decidua  is  not  to  be  looked  upon  as  a  preparation  for  the  ovum,  that 
menstruation  is  not  an  abortion  of  the  unfertilized  ovum,  and  that  ovulation 
does  not  necessarily  coincide  with  menstruation. 

In  weighing  the  evidence  above  set  forth  from  the  embryological  point  of 
view,  we  must  bear  in  mind  the  important  fact  that  in  many  of  these  reports 
no  mention  is  made  of  the  condition  of  the  ovaries,  and  that  when  such 
mention  is  made,  the  presence  of  a  well  developed  corpus  luteum  is  usually 
taken  as  evidence  that  ovulation  has  taken  place  just  previously.  This  view, 
however,  as  we  have  seen  (Chapter  V),  has  been  disproved  by  recent  his- 
tological studies  of  the  life  cycle  of  the  corpus  luteum,  indicating  that  the 
fully  formed  corpus  luteum  is  the  product  of  a  progressive  developmental 
change  extending  over  many  days,  which  takes  place  in  the  wall  of  the 
follicle  after  the  extrusion  of  the  follicles.  This  fact  detracts  greatly  from 
the  value  of  such  evidence  as  has  been  presented  in  this  section. 

Histological  Studies  of  Ovary. —  Although  we  are  indebted  to 
Fraenkel  for  the  first  experimental  effort  to  determine  which  element  in  the 
ovary  is  responsible  for  menstruation,  and  although  this  author  also  deduced 
from  his  observations  the  period  at  which  ovulation  occurs,  it  was  not 
until  the  work  of  Meyer  and  Ruge  that  a  method  of  histological  study  was 
resorted  to  which  appeals  to  be  free  from  serious  objection.  This  was  not 
true  of  the  work  of  Fraenkel,  as  has  already  been  discussed  (Chapters  V  and 
VII).  The  latter  author  placed  the  date  of  ovulation  at  about  the  fifteenth 
to  the  twentieth  days  of  the  menstrual  cycle. 

The  studies  of  Meyer  and  Ruge  have  already  been  described  at  some 
length  in  Chapters  V  and  VII,  as  well  as  the  corroborative  investigations  of 
Miller  and  Schroder.  It  is  therefore  necessary  only  to  summarize  briefly 
the  results  of  these  various  authors  as  they  relate  to  the  correlation  of 
menstruation  and  ovulation. 

The  plan  of  study  pursued  was,  in  general,  a  study  of  the  cyclical  histologi- 
cal changes  in  the  corpus  luteum  during  the  various  stages  of  the  menstrual 
cycle.  The  latter  were  determined,  not  by  the  uncertain  means  of  the 
menstrual  history,  but  by  a  correlative  histological  study  of  the  endometrium. 
By  this  method  Meyer  and  Ruge  were  able  to  demonstrate  that  the  life  of 
the  corpus  luteum,  as  such,  begins  at  some  period  between  the  first  and  four- 
teenth days  of  the  menstrual  cycle,  and  that  it  then  passes  through  a  series 
of  cyclical  changes  which  correspond  to  and  produce  those  noted  in  the 
endometrium.  In  other  words,  ovulation  takes  place,  according  to  these 
observers,  either  in  the  postmenstrual  or  interval  periods  of  the  menstrual 
cycle. 

Miller's  studies  yielded  a  substantial  confirmation  of  the  results  arrived 


RELATION  OF  MENSTRUATION  AND  OVULATION  159 

at  by  Meyer  and  Ruge,  in  that  ovulation  was  found  to  occur  in  the  intermen- 
strual periods.  The  exact  time  was,  however,  placed  somewhat  later  in  the 
menstrual  cycle  than  by  Meyer  and  Ruge,  the  process  occurring-  on  about 
the  nineteenth  day  of  the  cycle,  i.  e.,  about  nine  days  before  the  onset  of  the 
succeeding  menstrual  period. 

My  own  study  of  five  specimens  of  very  early  corpora  lutea  indicates  that 
ovulation  occurs  practically  always  in  the  first  half  of  the  intermenstrual 
period,  and  probably  most  frequently  between  the  seventh  and  fourteenth 
days.  The  number  of  very  early  corpora  lutea  reported  from  all  sources, 
however,  is  still  very  small  —  certainly  not  over  twelve  —  and  hence  there  is 
great  need  of  pushing  work  along  this  promising  line. 

Schroder's  investigations  of  this  subject  are  of  interest  in  that  he  especi- 
ally has  made  an  effort  to  correlate  the  histological  findings  in  the  corpus 
luteum  with  those  in  the  uterine  mucosa.  He  places  the  occurrence  of 
ovulation  at  a  period  between  the  fourteenth  and  sixteenth  days  of  the  cycle. 
The  secretory  activity  of  the  utricular  glands,  so  characteristic  of  the  pre- 
menstrual period,  he  attributes  to  the  influence  of  the  maturing  corpus 
luteum,  while  the  moderate  proliferative  changes  noted  in  the  glands  before 
the  period  of  ovulation  he  believes  are  due  to  the  influence  of  the  ripening 
graafian  follicle  before  it  ruptures. 

Summary  of  Histological  Evidence. —  This  method  of  investigation 
appears  to  be  much  more  reliable  than  the  others  which  have  been  discussed. 
The  results  of  the  histological  method  of  study  indicate  clearly  that  a  very 
definite  relation  exists  between  menstruation  and  ovulation,  but  that  they 
do  not  occur  synchronously.  Ovulation  occurs  in  the  intermenstrual  period, 
its  exact  date  probably  varying  in  different  women,  but  falling  usually 
between  the  fifth  and  fourteenth  days  of  the  cycle.  Menstruation  cannot 
occur  without  a  preceding  ovulation,  although  women  often  ovulate  when 
not  menstruating. 

XVI 
LITERATURE 

Ahlfeld.  Beobachtungen  iiber  die  Dauer  der  Schwangerschaft.  Monats.  f. 
Geburtskunde,  1869,  34,  180. 

voN  Baer.     De  Ovi  Mamalium  Genesi  Epistola.     Lipsiae,  1827. 

Bill.  Clinical  Evidence  of  Relation  of  Menstruation,  Ovulation,  and  Fertil- 
ization.    Cleveland  M.  J.,  1910,  9,  505. 

VON  BiscHOFF.  Ueber  Menstruation  und  Ovulation.  Wien.  Med.  Wchnsch., 
1875,  25,  449. 

Entwicklungsgeschichte   der    Saugetiere   und    der    Menschen.     Leipzig, 

1842. 

Carmichael  and  Marshall.  The  Correlation  of  Ovarian  and  Uterine  Func- 
tion.    Brit.  M.  J.,  1907,  2,  1572. 

Chazan.  Menstruation  und  Ovulation ;  Eine  Kritische  Studie.  Arch,  f .  Gyn., 
1889,  36,  27. 


160  MENSTRUATION  AND  ITS  DISORDERS 

CoHXSTEiN".  Beitrag  zur  Lehre  von  der  Ovulation  und  Menstruation. 
Deutsch.  Med.  Wchnsch.,  1890,  16,  764. 

Corner  and  Hurxi.  Non-effect  of  Corpus  Lnteum  on  Ovulation  Cycle  of  Rut. 
Amer.  J.  Physiol,  191 8,  46,  483. 

Fraenkel.     Die  Funktion  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1903,  68,  438. 

Neue  Experimente  zur  Funktion  des  Corpus  Luteums.     Arch.  f.  Gyn., 

1910,91,705. 

Frank.  Clinical  Manifestations  of  Disease  of  Glands  of  Internal  Secretion  in 
Gynecological  and  Obstetrical  Patients.  Surg.,  Gyn,,  and  Obst.,  1914, 
19,  608. 

Gendrin.     Traite  philosophique  de  medicine  pratique.     Paris,  1839. 

Heape.  On  Menstruation  and  Ovulation  in  Monkeys  and  in  the  Human 
Female.     Brit.  M.  J.,  1898,  2,  1868. 

Hyrtl.     Lehrbuch  der  Anatomic  des  Menschen.     Prag,  1846. 

Ingalt.s.  Relation  between  Ovulation,  Menstruation  and  Fertilization  as 
Shown  by  Some  Early  Human  Embryos.     Cleveland  M.  J.,  1909,  9,  511. 

IsSMER.  Ueber  die  Zeitdauer  der  Menschlichen  Schwangerschaft.  Arch.  f. 
Gyn.,  1889,  35,  310. 

Keibel  and  Mall.     Human  Embryology.     Philadelphia,  1910. 

Keller.  Uber  Veranderungen  am  Follikelapparat  des  Ovariums  wahrend  der 
Schwangerschaft.     Beitrage  f.  Geb.  u.  Gyn.,  1914,  19,  13. 

Leopold  und  Mironoff.  Beitrag  zur  Lehre  von  der  Menstruation  und  Ovula- 
tion.    Arch.  f.  Gyn.,  1894,  45,  506. 

und  Ravano.  Neuer  Beitrag  zur  Lehre  von  der  Menstruation  und  Ovu- 
lation.    Arch.  f.  Gyn.,  1907,  83,  566. 

Marcotty.  Ueber  das  Corpus  Luteum  Menstruationis  und  das  Corpus 
Luteum  Graviditatis.     Arch.  f.  Gyn.,  1914,  103,  62. 

Marshall  and  Runciman.  On  the  Ovarian  Factor  Concerned  in  the  Recur- 
rence of  the  Oestrous  Cycle.     Journal  of  Phys.,  1915,  49,  17. 

Meyer.  Ueber  die  Beziehung  der  Eizelle  und  das  Befruchteten  Eies  zum  Fol- 
likelapparat, sowie  des  Corpus  Luteum  zur  Menstruation.  Arch,  f .  Gyn., 
1913,  100,  I. 

Negrier.  Recherches  anatomiques  et  physiologiques  sur  les  ovaires  dans 
I'espece  humaine.     Paris,  1840. 

Novak.  The  Corpus  Luteum  —  Its  Life  Cycle  and  its  Role  in  Menstrual  Dis- 
orders.    Jour.  A.  M.  A.,  1916,  67,  1285. 

PoucHET.  Theorie  positive  de  I'ovulation  spontanee  et  de  la  fecondation,  etc. 
Paris,  1847. 

PuECH  ET  VoNVERTS.  Du  role  du  corps  jaune  dans  I'ovulation  et  le  develop- 
ment de  I'oeuf  chez  la  femme.  Rev.  Mens,  de  Gyn.,  Obst.  et  de  Pediat., 
I9i3>  7,  236. 

Racihorski.     De  la  puberte  et  de  I'age  critique  chez  la  femme,  etc.    Paris,  1844. 

Reicuert.  Beschreibung  einer  Friihzeitiger  Menschlichen  Frucht  in  Blasen- 
formigen  Bildungszustande.  Abhandl.  d.  Konigl.  Akad.,  d.  Wissen- 
schaften.     Berlin,  1883. 

Riebold.  Beobachtungen  der  Inneren  Klinik  iiber  die  Beziehungen  der  Ovu- 
lation zur  Menstruation.  Verhandl.  d.  Kong.  f.  Innere  Medizin. 
(Wiesbaden)   1908,  25,  107. 


RELATION  OF  MENSTRUATION  AND  OVULATION  161 

RuGE.     Ueber  Ovulation,  Corpus  Luteum,  und  Menstruation.     Arch.  f.  Gyn., 

1913,  100,  20. 
Schroder.     Neue  Aussichten  iiber  die  Menstruation  und  ihre  Zeitliches  Ver- 

halten  zur  Ovulation.     Monatschr.  f.  Geb.  un  Gyn.,  19 13,  38,  i. 
Seitz.     Ueber     Follikelreifung     und     Ovulation     in     der     Schwangerschaft. 

Zentralb.  f.  Gyn.,  1908,  32,  ;^;^2. 
Waite.     Relation  of  Menstruation,  Ovulation  and   Pregnancy   in   Mammals. 

Cleveland  M.  J.,  1909,  9,  513. 
Williams.     Textbook  of  Obstetrics.     New  York,  1917. 
ZiNKE.     Menstruation ;  its  Anatomy,  Physiology,  and  Relation  to  Ovulation. 

Amer.  J.  Obst.,  1891,  24,  810. 


CHAPTER  XVII 

RELATION  OF  MENSTRUATION  TO  LACTATION 

Is  Amenorrhea  the  Rule  During  Lactation?  —  It  is  a  well  known 
fact  that  in  a  large  proportion  of  cases  menstruation  is  absent  while  a  woman 
is  nursing  her  child.  Indeed,  the  absence  of  menstruation  during  this  time 
has  usually  been  looked  upon  as  the  rule.  It  is  believed  by  many,  however, 
that  in  the  great  majority  of  cases  menstruation  reappears  before  the  cessa- 
tion of  lactation.  For  example,  Ehrenfest  quotes  Czerny  and  Keller  as 
stating:  "  We  will  emphasize  the  fact,  apparently  not  generally  appreciated, 
that  the  reappearance  of  menstruation  during  lactation  is  the  normal,  and 
that  persistent  amenorrhea  is  the  exception." 

Statistics  Bearing  on  the  Discussion. —  Ehrenfest  found  that  in  a 
total  of  257  lactating  women  the  first  menstruation  reappeared  in  132  in- 
stances (51.3  per  cent)  within  twelve  weeks  post  partum.  In  primiparous 
women  the  proportion  amounted  to  52.3  per  cent.  Of  the  total  number  of 
cases,  it  was  found  that  83.3  per  cent  menstruated  before  weaning  the  child, 
only  16.6  per  cent  exhibiting  amenorrhea  throughout  lactation. 

Thiemich,  on  the  other  hand,  from  an  investigation  of  some  1200  cases, 
concluded  that  menstruation  does  not  appear,  so  long  as  the  woman  suckles 
the  baby  and  gives  no  other  food  whatsoever.  When,  on  the  other  hand, 
the  woman's  breasts  are  called  upon  for  only  a  part  of  the  baby's  nourish- 
ment, menstruation  not  infrequently  reasserts  itself. 

Essen-Moller  states  that  menstruation  reappeared  in  60  per  cent  of  427 
women  whom  he  examined  during  lactation.  In  about  one  third  the  cases 
it  reappeared  during  the  first  two  months  after  childbirth.  A  somewhat 
similar  study  by  Heil  is  based  on  200  cases.  His  experience  shows  that 
about  one  half  of  all  nursing  women  menstruate  regularly.  He  gives  a 
number  of  reasons  which  lead  him  to  think  that  the  woman  who  menstruates 
during  this  period  represents  the  normal  type. 

The  statistics  of  Remfry  showed  that  of  900  nursing  women  whom  he 
studied  43  per  cent  menstruated  and  57  per  cent  did  not.  Brickner  found 
menstruation  occurring  in  43.3  per  cent  of  442  nursing  mothers ;  Glass  in 
40  per  cent  of  1200  cases;  Sundin  in  from  55  to  59  per  cent  of  335  nursing 
women. 

Finally,  reference  may  be  made  to  the  statistics  of  Pinard,  obtained  from 
the  records  of  10,886  women  who  had  been  confined  at  the  Baudelocque. 
He  says  that  of  women  who  are  nursing  for  the  first  time  27  per  cent  have 
no  menses  during  lactation ;  if  pregnant  for  the  second  time  35  per  cent  do 

162 


RELATION  OF  MENSTRUATION  TO  LACTATION  163 

not  menstruate;  if  for  the  third  time,  60  per  cent  do  not  menstruate, 
whatever  the  duration  of  lactation. 

Reasons  for  the  Discrepancy  in  Statistics. —  It  will  be  noted  that  the 
figure  given  by  Ehrenfest  as  representing  the  frequency  with  which  men- 
struation occurs  at  some  time  during  lactation  (81.3  per  cent)  is  much 
higher  than  the  figures  given  by  any  of  the  other  authors  quoted  above. 
This  is  explained  by  Ehrenfest  as  being  due,  in  pa.rt,  to  the  fact  that  he 
counts  a  case  as  menstruating  if  the  first  menstruation  appears  in  less  than 
three  weeks  after  weaning  of  the  infant. 

Much  more  important,  to  my  mind,  is  the  fact  that  Ehrenfest's  figures  are 
based  upon  a  knowledge  of  the  menstrual  history  throughout  the  entire 
course  of  lactation,  the  exact  date  of  the  first  flow  and  of  the  cessation  of 
lactation  being  known.  On  the  other  hand,  the  statistics  of  most  of  those 
who  have  written  on  the  subject  are  obtained  by  questioning  nursing  women 
as  to  the  presence  or  absence  of  menstruation.  Not  infrequently  menstrua- 
tion is  absent  at  the  time  of  questioning,  but  reappears  later  during  lactation. 
It  seems  reasonable  to  believe  that  figures  obtained  by  such  faulty  methods 
of  observation  can  be  only  approximately  correct,  and  that  the  actual  propor- 
tion of  lactating  women  who  menstruate  is  more  nearly  represented  by 
Ehrenfest's  figures. 

Cause  of  Amenorrhea  During  Lactation. —  While  we  are  in  the  habit 
of  speaking  of  amenorrhea  as  a  physiological  state  during  lactation,  we  can 
only  theorize  as  to  the  mechanism  of  its  production.  In  the  first  place,  this 
question  is  of  course  quite  separate  from  the  consideration  of  the  cause  of 
lactation.  The  latter,  it  may  be  parenthetically  stated,  is  believed  to  be  due 
to  a  hormone  originating  in  the  placenta  (Halban)  or  in  the  ovary  (Stein- 
ach,  Athias).  In  view  of  the  very  great  resemblance  in  the  behavior  of 
placental  and  corpus  luteum  extracts,  Frank  very  plausibly  suggests  that 
the  placenta,  instead  of  manufacturing  a  hormone  of  its  own,  acts  merely 
as  a  reservoir  for  the  corpus  luteum  substance  in  the  latter  half  of  pregnancy. 

In  view  of  our  lack  of  knowledge  as  to  the  exact  mechanism  of  men- 
struation, it  seems  scarcely  profitable  to  speculate  as  to  the  reasons  for  the 
frequent  absence  of  the  phenomenon  during  lactation.  As  we  have  already 
seen  (Chapter  VII),  the  most  recent  investigations  attribute  to  the  corpus 
luteum  the  principal  role  in  the  causation  of  the  menstrual  flow.  There  is 
abundant  evidence  as  to  the  occurrence  of  ovulation  during  lactation.  Obvi- 
ously, new  corpora  lutea  are  continually  being  formed  in  such  cases,  and  yet 
menstruation  does  not  occur.  What  new  factor  it  is  that  counteracts  or 
inhibits  the  activity  of  the  corpus  luteum,  if  the  latter  be  assumed  to  cause 
menstruation,  has  not  been  definitely  determined.  It  would  certainly  seem 
that  the  lactating  mammary  gland  is  directly  or  indirectly  responsible  for 
this  inhibition,  most  probably  through  the  agency  of  a  hormone.  This  view, 
however,  is  as  yet  supported  by  no  reliable  experimental  evidence. 

Fraenkel  believes  that  menstruation  is  absent  during  lactation,  owing  to 
the  debilitating  influence  of  the  latter  upon  the  woman's  organism,  and  that 


164  MENSTRUATION  AND  ITS  DISORDERS 

when  the  strength  and  vitahty  of  the  woman  reasserts  itself,  menstruation 
reappears,  even  though  lactation  still  be  kept  up.  The  evidence  in  favor  of 
this  theory,  however,  is  not  by  any  means  convincing. 

Ovulation  During  Lactation. —  Numerous  clinical  reports  have  been 
made  indicating  the  possibility  of  ovulation,  as  manifested  by  pregnancy, 
during  lactation.  Indeed,  the  occurrence  of  pregnancy  during  the  period 
of  lactation  is  so  common  that  cases  of  this  type  are  familiar  to  all  prac- 
titioners of  medicine.  The  rather  striking  cases  of  Roudellet,  Joubert, 
Meigs  and  Chrobak  have  already  been  mentioned  in  the  chapter  on 
"  Menstruation  and  Ovulation." 

Fraenkel  believed  that  when  impregnation  occurs  during  lactation  it  is 
as  a  rule  in  women  who  are  amenorrheic,  rather  than  those  who  have  again 
begun  to  menstruate.  His  views,  however,  are  not  substantiated  by  the 
work  of  other  investigators. 

The  statistics  of  Remfry,  on  the  contrary,  indicate  that  the  probability  of 
pregnancy  is  much  greater  in  nursing  women  who  menstruate  than  in  those 
who  do  not  menstruate.  In  the  former  group  the  chance  of  pregnancy  is 
placed  at  6  in  lo,  while  in  the  latter  class  it  is  only  6  in  lOO. 

In  Ehrenfest's  series  of  209  cases,  there  were  4  cases  of  pregnancy  in 
amenorrheic  women  during  lactation,  as  compared  with  22  cases  in  which 
the  pregnancy  followed  the  first  menstruation.  This  is  in  accordance  with 
the  observation  of  Heil,  who  found  that  pregnancy  occurred  during  amenor- 
rhea in  only  29  per  cent  of  women  during  lactation,  the  remaining  71  per 
cent  having  menstruated  one  or  more  times. 

It  seems  fair  to  conclude  that,  while  a  nursing  woman  may  become  preg- 
nant either  before  or  after  menstruation  has  reappeared,  the  occurrence  is 
much  more  frequent  in  those  women  in  whom  the  menstrual  function  has 
reestablished  itself. 

Influence  of  Menstruation  on  Breast  Milk. —  It  cannot  be  said  that 
opinion  is  unanimous  with  regard  to  the  influence  of  menstruation  on  the 
character  and  amount  of  the  milk  secreted  by  the  breasts  of  the  lactating 
woman.  This  is  a  question  of  some  practical  importance,  for  a  physician 
is  frequently  asked  whether  breast  feeding  may  safely  be  kept  up  during 
menstruation.  At  the  outset  it  may  be  said  that  this  question  can  practi- 
cally always  be  answered  in  the  affirmative.  From  the  observation  of  a 
considerable  number  of  such  cases,  I  am  convinced  that  it  is  rare  indeed  for 
menstruation  to  cause  any  alteration  in  the  character  of  the  milk,  which  will 
work  any  injury  to  the  child.  It  is  true  that  occasionally  the  child  will 
show  slight  gastric  disturbances  during  this  period,  and  it  is  perhaps  true 
that  in  a  small  proportion  of  women  the  systemic  influence  of  the  menstrual 
phenomenon  is  sufficient  to  bring  about  a  transient  alteration  of  the  milk 
secretion.  Nevertheless,  it  is  a  safe  rule  to  assume  that  there  is  no  risk 
incident  to  a  continuance  of  breast  feeding  during  menstruation. 

The  most  recent  study  of  this  problem  is  that  of  Grulee  and  Caldwell, 
These  authors  cite  the  work  of  Vernois  and  Becquerel  in  1853  ^^^  ^hat  of 


RELATION  OF  MENSTRUATION  TO  LACTATION  165 

Davis  in  1856,  concluding  that  little  dependence  can  be  placed  in  their 
results,  owing  to  faulty  methods  of  study.  The  one  case  upon  which  their 
own  report  is  based  was  that  of  "  a  baby  born  with  a  harelip  and  cleft  palate, 
nursed  for  nine  months  by  means  of  a  specially  devised  breast  pump.  The 
mother's  menstrual  period  began  six  weeks  after  birth  and  continued 
throughout  the  nursing.  The  quantity  of  milk  was  carefully  measured, 
especially  during  the  last  four  months  of  lactation,  and  there  was  shown  a 
distinct  relation  between  the  quantity  of  breast  milk  and  the  occurrence  of 
the  menstrual  period.  This  consisted  in  a  period  of  increase  of  breast  milk, 
beginning  with  the  first  day  of  menstruation  and  lasting  from  ten  days  to 
two  weeks  thereafter.  There  then  occurred  a  diminution  in  the  quantity, 
which  reached  its  lowest  point  four  to  seven  days  previous  to  menstruation, 
after  which  there  was  a  gradual  increase." 

The  objections  which  at  once  suggest  themselves  as  invalidating  the  value 
of  this  observation  are  the  possibility  of  a  psychic  influence  on  the  mother, 
and,  what  is  even  more  important,  the  fact  that  the  conditions  under  which 
the  milk  was  collected  were  anything  but  natural.  The  effort  of  the  authors 
to  minimize  the  importance  of  these  factors,  more  especially  of  the  second, 
is  not  convincing,  and  their  findings  must  be  looked  upon  as  only  suggestive. 

As  for  the  effect  of  menstruation  upon  the  chemical  composition  of  the 
breast  milk,  the  available  reports  are  practically  all  of  a  negative  nature. 
Pfeiffer,  Bamberg,  Thiemich  and  Schlicter  all  find  that  menstruation  causes 
no  changes  in  the  chemical  composition  of  the  milk  which  seem  more  im- 
portant than  the  slight  variations  seen  in  all  women  at  various  times  and 
as  a  result  of  various  individual  influences. 

XVII 
LITERATURE 

Bamberg.  Zur  Physiologie  der  Lactation  mit  Besonderer  Beriicksichtigung 
der  Chemischen  Zusammensetzung  der  Frauenmilch  und  des  Einflusses 
der  Menstruation.     Zeitsch.  f.  Kinderh.,  1913,  6,  430. 

Brickner.  a  Contribution  to  the  Study  of  Menstruation  and  Pregnancy  in 
Nursing  Women.     Phila.  M.  J.,  1899,  4,  266. 

Ehrenfest.     Menstruation  and  Childbirth.     Amer.  J.  Obst.,  191 5,  y2,  577. 

EssEN-MoLLER.  Ucbcr  das  Verhalten  der  Menstruation  wahrend  des  Stillens. 
Zentral.  f.  Gyn.,  1906,  30,  175. 

Fellner.  Ueber  die  Thatigkeit  des  Ovariums  in  der  Schwangerschaft.  Arch, 
f.  Gyn.,  1908,  87,  318. 

Fraenkel.     Liepmann's  Handb.  d.  Frauenheilkunde,  1914,  bd.  3. 

Glass.     Die  Menstruationsverhaltnisse  der  Stillenden.     Zentral.  f.  Gyn.,  19 12, 

36,957- 
Gottschalk.     Zur  Frage  der  Beziehung  der  Menstruation   zur  Konzeption 

und  zur  Einbettung.     Ztschr.  f.  Geb.  u.  Gynak.,  1910,  67,  492. 

Grulee  and  Caldwell.     Influence. of  Menstruation  on  Breast  Milk.     Amer. 

.      J.  Dis.  Children,  1915,  9.  7. 


166  MENSTRUATION  AND  ITS  DISORDERS 

Halban.     Schwangerschaftsreactionen  der  Foetalen  Organen,  etc.     Zeitsch.  f. 

Geb.  u.  Gyn.,  1904,  53,  191. 
Heil.     Laktation  und  Menstruation.     Monats.  f.  Geb.  u.  Gyn.,  1906,  23,  340. 
Keller.     Ueber  Veranderungen  am  Follikelapparat  des   Ovariums   wahrend 

des  Schwangerschaft.     Beitrage  z.  Geb.  u.  Gyn.,  1914,  19,  13. 
Pfeiffer.     Beitrage  zur  Physiologie  der  Muttermilch  und  ihren  Beziehungen 

zur  Kinderernalirung.     Jahrb.  f.  Kinderh.,  1883,  20,  359. 
Remfry.     The  Effects  of  Lactation  on  Menstruation  and  Impregnation.    Brit. 

M.  J.,  1896,  I,  86. 
ScHATZ.     Die     erste     Menstruation     nach     der     Entbindung.     Wien.     Med. 

Wchnsch.,  1908,  58,  2842. 
Schlicter.     Ueber  den  Einfluss  der  Menstruation  auf  die  Lactation.     Wien. 

Klin.  Wchnsch.,  1889,  2,  978;  1004;  also  1890,  3,  66;  88. 
SuNDiN.     Zur  Frage  der  Menstruation  wahrend  des  Stillens.     Zentralbl.   f. 

Gyn.,  1908,  33,  242. 
Thiemich.     Ueber  Veranderungen  der  Frauenmilch  durch  Physiologische  und 

Pathologische  Zustande ;  ein  Kritisches  Sammelreferat.    Monats.  f .  Geb. 

u.  Gyn.,  1898,  8,  521 ;  645. 


CHAPTER  XVIII 


AMENORRHEA 


Definition  and  Varieties. —  Amenorrhea  is  the  condition  in  which 

menstruation  is  absent  during  the  reproductive  period  of  the  woman's  life. 
Two  varieties  are  usually  distinguished,  a  primary  and  secondary. 

Primary  Amenorrhea. —  By  primary  amenorrhea  is  meant  the  con- 
dition in  which  menstruation  fails  to  occur  at  the  usual  age  in  girls.  In 
view  of  the  great  individual  differences  in  young  girls  as  to  the  age  at 
which  the  menstrual  function  is  inaugurated,  it  is  difficult  to  fix  any  arbi- 
trary limit  beyond  which  the  onset  of  menstruation  may  be  looked  upon 
as  abnormally  tardy.  Speaking  generally,  the  failure  of  menstruation  to 
appear  before  the  age  of  seventeen  may  be  considered  to  justify  the  designa- 
tion of  primary  amenorrhea. 

Secondary  Amenorrhea. —  Secondary  amenorrhea,  on  the  other  hand, 
has  reference  to  the  absence  of  menstruation  after  the  function  has  already 
become  established.  To  illustrate,  if  a  woman  of  thirty,  who  has  always 
menstruated  regularly,  misses  her  period  one  or  more  months,  she  may  be 
said  to  be  suffering  with  amenorrhea  of  the  secondary  variety. 

Distinction  Between  Amenorrhea,  Retention  of  Menses  and  Suppres- 
sion of  Menses. —  These  three  terms  are  often  confused  one  with 
another.  Aside  from  purely  academic  considerations,  it  seems  to  me  that 
a  distinction  should  be  drawn  between  them,  if  one  is  to  have  an  intelligent 
conception  of  their  significance. 

In  true  amenorrhea,  all  the  pelvic  phenomena  characteristic  of  menstrua- 
tion are  absent.  The  causative  stimulus,  whatever  it  may  be,  is  apparently 
lacking,  so  that  there  is  complete  absence  of  the  vascular,  endometrial  and 
other  changes  normally  associated  with  menstruation. 

On  the  other  hand,  all  these  changes  may  be  present  in  certain  cases  in 
which  there  is  no  menstrual  discharge  whatsoever.  Many  text  books  give 
among  the  causes  of  amenorrhea  the  various  forms  of  mechanical  occlusion 
of  the  genital  canal,  which  prevent  the  exit  of  the  menstrual  blood.  Cases 
of  this  type,  however,  are  merely  instances  of  retention  of  menses. 
]\Ienstruation  may  occur  under  these  conditions  as  normally,  the  only  dif- 
ference being  that  the  menstrual  blood  can  not  make  its  appearance 
externally. 

Of  somewhat  less  importance  is  the  distinction  between  amenorrhea  and 
suppression  of  the  menses.     The  latter  term  is,  strictly  speaking,  to  be 

167 


168  MENSTRUATION  AND  ITS  DISORDERS 

applied  to  a  suppression  or  cessation  of  an  individual  menstrual  period  after 
it  has  once  been  inaugurated.  To  illustrate,  if  a  woman,  as  a  result  of 
getting  the  feet  wet  on  the  first  day  of  menstruation,  suddenly  ceases  to 
menstruate,  she  is  suffering  with  suppression  of  the  flow.  The  severe  pain 
often  experienced  in  this  condition  emphasizes  the  difference  between  it 
and  amenorrhea,  in  which  there  is  no  pain,  and  usually  not  even  the  normal 
"  menstrual  molimina." 

I  am  aware  that  the  differentiation  made  here  between  these  three  terms 
is  either  not  recognized,  or  at  any  rate,  not  emphasized  by  most  authors, 
but  the  matter  would  seem  to  be  of  sufficient  interest  and  importance  to  merit 
mention. 

Classification  of  Causes  of  Amenorrhea. —  For  the  sake  of  conveni- 
ence, the  causes  of  amenorrhea  may  be  divided  into  local  and  general.  The 
former  embrace  such  conditions  as  absence  or  hypoplasia  of  one  or  more  of 
the  generative  organs,  or  acquired  pathological  conditions  of  the  pelvic 
organs.  The  general  causes,  on  the  other  hand,  have  to  do  with  various 
factors  of  extragenital  nature  perhaps  involving  the  organism  generally. 

The   principal   groups  of   causes   of   amenorrhea  may  be  tabulated   as 
follows : 
Local  causes : — 

1.  Congenital  absence  or  malformation  of  generative  organs. 

2.  Acquired  pathological  conditions  of  generative  organs. 
General  causes : — 

1.  Physiological    (puberty,   menopause,  pregnancy,   and  lactation). 

2.  Functional  (sudden  shock,  excitement,  chilling  or  wetting  of  skin, 
change  of  climate). 

3.  Acute  infectious  diseases  (acute  exanthemata,  typhoid,  pneumonia, 
malaria,  etc.). 

4.  Constitutional  diseases  (tuberculosis,  chlorosis,  diabetes,  nephritis, 
etc.). 

5.  Mental  disturbances,  especially  insanity. 

6.  Disorders  of  the  ductless  glands. 

Local  Causes. —  Congenital  Absence  or  Malformations  of  Repro- 
ductive Organs. —  Congenital  absence  of  the  uterus,  of  both  ovaries,  or  of 
both  uterus  and  ovaries,  is  of  course  incompatible  with  the  occurrence  of 
menstruation.  In  such  cases  the  amenorrhea  is  of  the  primary  type.  A  con- 
siderable number  of  such  cases  have  been  recorded,  absence  of  the  uterus 
being  much  more  common  than  absence  of  the  ovaries. 

The  following  personal  case  illustrates  this  type  of  amenorrhea : 

L.  S.,  age  205^  years,  had  never  menstruated  and  had  never  observed 
definite  menstrual  molimina.  She  was  slender  but  well  formed,  and  not 
anemic.  The  breasts  were  fairly  well  developed,  and  there  was  a  normal 
growth  of  hair  on  the  mons  veneris  and  in  the  axillae. 

Examination  under  anesthesia  showed  the  vulva,   at  first  sight,  to  be 


AMENORRHEA  169 

normal.  The  hymen  was  of  the  annular  type,  and  not  imperforate,  the 
opening  being  about  i  cm.  in  diameter. 

Just  within  this  was  what  seemed  at  first  like  a  second  and  imperforate 
hymen,  but  which  was  simply  the  floor  of  a  shallow  fossa  less  than  i  cm. 
deep,  marking  the  usual  orifice  of  the  vagina.  No  evidence  of  the  latter 
could  be  found.  Careful  bimanual  examination  through  the  rectum  failed 
to  disclose  any  sign  of  the  uterus  except  an  indistinct  transverse  ridge 
behind  the  bladder.  The  thinness  of  the  abdominal  walls  and  their  relaxa- 
tion by  the  anesthetic  made  examination  extremely  easy.  Both  ovaries 
were  plainly  palpable  in  their  normal  positions.  The  amenorrhea  was 
obviously  due  to  congenital  absence  of  the  uterus.  This  case,  together 
with  a  second  of  similar  nature,  encountered  in  my  own  practice,  and  four 
others  which  have  been  observed  in  the  gynecological  clinic  of  the  Johns 
Hopkins  Hospital,  were  reported  by  me  in  a  recent  paper. 

Hypoplasia  of  the  uterus  also  may  be  associated  with  a  condition  of 
amenorrhea,  as  is  so  frequently  noted  in  women  with  an  infantile  type  of 
uterus. 

Congeiiital  absence  of  the  fallopian  tubes,  theoretically  at  least,  might 
be  expected  to  exert  no  more  influence  on  the  occurrence  of  menstruation 
than  does  the  surgical  removal  of  the  tubes  which  is  so  frequently  carried 
out.  It  is  difficult,  therefore,  to  explain  the  case  reported  by  Spencer  in 
191 1,  in  which  congenital  absence  of  the  tubes  was  associated  wdth  amen- 
orrhea. His  patient  was  a  single  woman,  age  28,  who  complained  of 
attacks  of  pain  in  the  right  iliac  fossa.  She  had  never  had  any  sign  of 
menstruation.  The  external  genitalia  and  the  breasts  were  normal.  The 
uterus,  at  operation,  was  found  to  be  normal,  and  in  place  of  each  cornu 
there  was  found  a  pea-like  knob.  The  ovaries  were  present,  being  buried 
under  a  layer  of  peritoneal  adhesions.  No  sign  of  the  fallopian  tubes  was 
found. 

In  spite  of  the  association  in  this  case  of  amenorrhea  with  absence  of  the 
fallopian  tubes,  there  is  no  justification  for  the  assumption  that  they  are 
related  as  cause  and  effect.  As  a  matter  of  fact,  all  the  evidence  furnished 
by  modern  investigations  speaks  strongly  against  any  such  influence  on  the 
part  of  the  tube. 

As  for  congenital  absence  or  atresia  of  the  lower  portion  of  the  genital 
canal  (Fig.  28),  i.  e.,  the  cervix  or  the  vagina,  or  both,  we  need  only  say 
that  such  anomalies  result  in  a  retention  of  the  menstrual  blood  above  the 
point  of  mechanical  obstruction.  The  results  of  such  obstruction  to  the  free 
exit  of  the  menstrual  blood  are  considered  in  Chapter  XIX. 

Acquired  Pathological  Conditions  of  Pelvic  Organs. —  Amenor- 
rhea, or  scanty  menstruation,  as  a  symptom  of  local  disease  in  the  pelvis, 
is  far  less  frequent  than  the  opposite  condition  of  excessive  menstrual  bleed- 
ing. The  tendency  of  practically  all  the  usual  forms  of  pelvic  disease,  such 
as  the  inflammatory  conditions  and  the  neoplasms,  is  to  produce  menor- 
rhagia  rather   than    deficient   menstruation.      Occasionally,   however,    the 


170 


MENSTRUATION  AND  ITS  DISORDERS 


pathological  lesions  are  of  such  a  form  as  to  involve  serious  impairment  of 
the  endometrium  or  of  the  secreting  structure  of  both  ovaries.  In  either 
case  the  result  may  be  cessation  of  menstruation. 

Atrophy  of  the  endometrium,  with  resulting  amenorrhea,  is  especially- 
apt  to  occur  in  connection  with  grave  puerperal  infections.  Occasionally 
even  gangrene  of  the  endometrium  occurs  under  such  conditions,  the  slough- 
ing endomentrium  being  cast  off  from  the  uterus  with  resulting  scar  formation. 
In  most  cases  of  puerperal  infection  of  such  virulent  type,  the  patient  suc- 
cumbs. If  she  recovers, 
menstruation  frequently 
fails  to  reappear.  Similar 
atrophic  changes  in  the  en- 
dometrium are  occasionally 
noted  after  acute  and  viru- 
lent gonorrheal  infections, 
as  well  as  in  association 
with  the  acute  exanthema- 
tous  diseases,  such  as  scarlet 
fever.  When  such  atrophic 
or  destructive  lesions  occur 
in  the  lower  part  of  the 
genital  canal,  the  result  is 
frequently  gynatresia,  with 
retention  of  the  menses. 

As  far  as  the  ovaries  are 
concerned,  the  only  type  of 
anatomic  alteration  capable 
of  inducing  amenorrhea  is 
one  which  involves  a  de- 
struction or  loss  of  func- 
tion of  all  secreting  ovarian 
tissue.  Such  a  sequel,  while 
not  very  common,  is  ob- 
served more  frequently  in 
connection  with  neoplasms 
than  with  inflammatory  dis- 
eases. In  a  recent  case  of 
my  own,  the  condition  found  at  operation  was  one  of  bilateral  dermoid 
cysts  of  the  ovaries.  Each  cyst  was  about  the  size  of  an  orange  and  had 
apparently  destroyed  the  entire  cortex  of  the  ovary.  The  woman,  who  was 
thirty-four  years  old,  had  not  menstruated  for  eight  months. 

General  Causes. —  Physiological  Amenorrhea. —  In  a  large  proportion 
of  cases  amenorrhea  is  noted  one  or  more  times  during  the  "  dodging " 
periods  of  puberty  and  the  menopause.  The  proportion  of  girls  who  men- 
struate regularly  from  the  very  inauguration  of  the  function  is  stated  by 


Fig.  28. —  Entire  Absence  of  the  Vagina,  With 
Indication  of  Double  Hymen. 

The  external  genitals  are  normal  (Kelly). 


AMENORRHEA  171 

Emmett  to  be  as  high  as  72.33  per  cent,  but  my  own  impression  is  that  this 
estimate  is  too  high.  It  is  extremely  common  for  girls  to  skip  one  or  more 
periods  from  time  to  time  during  the  first  year  or  two  of  menstrual  life. 
The  same  thing  is  true  of  the  other  end  of  the  reproductive  life,  the  meno- 
pause, for  the  complete  cessation  of  the  menstrual  function  is  often  pre- 
ceded by  periods  of  amenorrhea  of  varying  length. 

Amenorrhea  is  the  rule  during  pregnancy,  although  menstruation  may 
occur  occasionally  during  the  first  month  or  two  of  gestation.  Rarely  the 
periods  recur  for  a  longer  time,  cases  being  recorded  where  menstruation 
has  continued  up  to  the  seventh  month  of  pregnancy. 

As  regards  lactation,  the  statement  has  usually  been  made  that  amen- 
orrhea is  the  rule,  though  exceptions  are  freqvient.  As  a  matter  of  fact,  if 
the  history  be  followed  throughout  lactation,  i.  e.,  from  parturition  to  the 
weaning  of  the  child,  it  will  be  found  that  in  the  majority  of  cases  menstrua- 
tion returns  at  some  time  before  the  end  of  lactation.  The  proportion  of 
cases  in  which  menstruation  occurs  during  lactation  is  placed  by  Ehrenfest 
as  high  as  81.3  per  cent. 

For  a  further  discussion  of  these  subjects  the  reader  is  referred  to  Chap- 
ters IX,  XIII  and  XVII. 

Functional  Amenorrhea. —  This  term  is  not  altogether  satisfactory,  inas- 
much as  many  of  the  other  causes  herein  given  for  amenorrhea  are  also,  in 
the  final  analysis,  due  to  functional  derangements  of  the  ovary.  No  other 
term,  however,  suggests  itself  for  certain  cases  of  amenorrhea  which  occur 
in  the  absence  of  any  recognizable  disease,  either  local  or  general.  To 
this  group  belong  the  cases  in  which  chilling  of  the  body  or  zvetting  of  the 
feet  or  hands  inhibits  the  appearance  of  menstruation;  or  else,  if  it  has 
already  begun,  brings  about  sudden  checking  of  the  flow.  Cases  of  the 
latter  type  are  better  spoken  of  as  suppression  of  menses,  as  already 
suggested. 

The  same  inhibitory  influence  may  be  exerted  by  psychic  and  emotional 
disturbances.  The  best  illustration  of  the  powder  of  the  mind  over  the  men- 
strual function  is  furnished  by  the  frequent  occurrence  of  amenorrhea  in 
women  who  have  an  intense  longing  for  pregnancy,  or,  on  the  other  hand, 
in  unmarried  women  who  fear  that  they  may  be  pregnant.  Suppression  of 
the  menses  also  is  the  occasional  result  of  sudden  fright,  grief,  joy  or  other 
emotional  disturbances  in  the  menstruating  woman.  Many  cases  of  amenor- 
rhea were  observed  among  German  and  Austrian  women  during  the  recent 
war  (kriegsamenorrhoe) . 

Another  common  cause  of  functional  amenorrhea  is  change  of  climate. 
This  fact  has  been  known  for  a  long  time,  but  even  now  comparatively 
little  of  a  definite  nature  can  be  stated  as  to  the  exact  reason  for  this 
phenomenon.  I  have  had  an  opportunity  of  observing  it  in  many  immi- 
grants from  Europe  and  can  testify  to  its  great  frequency.  In  discussing 
the  comparative  physiology  of  menstruation  we  laid  great  stress  upon  the 
fact  that  the  function  is  greatly  influenced  by  climatic  and  environmental 


172  MENSTRUATION  AND  ITS  DISORDERS 

conditions.  (Chapter  II).  We  also  presented  evidence  in  favor  of  the 
view  that  the  polyestrous  sexual  season  of  the  human  female  probably  repre- 
sents an  evolution  from  a  primitive  non-estrous  cycle.  The  interesting  sug- 
gestion has  been  made  that  the  amenorrhea  so  frequently  seen  after  change 
of  climate  perhaps  represents  a  tendency  towards  reversion  to  the  primitive 
monestrous  type. 

Finally,  this  form  of  amenorrhea  is  often  observed  as  a  result  of  any  con- 
dition which  brings  about  a  deterioration  in  the  general  health  of  the  girl  or 
woman.  Such  factors  as  unhygienic  surroundings  and  overwork  are  of 
great  importance.  Not  only  the  amount  of  work,  but  also  its  character,  may 
be  very  harmful,  as  in  the  case  of  girls  who  are  employed  in  tobacco  fac- 
tories, tailor  shops,  department  stores,  etc.  Not  only  physical  overwork,  but 
also  mental  overtaxation,  is  apt  to  be  associated  with  amenorrhea,  so  that  it 
is  therefore  frequently  noted  in  the  growing  girl  who  is  being  overburdened 
with  school  work. 

Amenorrhea  Due  to  Acute  Infectious  Diseases. —  In  a  general  way  it  may 
be  said  that  the  influence  of  the  various  acute  infectious  diseases  upon  men- 
struation is  proportionate  to  the  severity  of  the  individual  case.  Mild  cases 
of  typhoid,  pneumonia,  or  other  diseases  of  this  type  sometimes  exert  very 
little  influence  on  the  course  of  menstruation. 

In  other  cases,  again,  and  almost  always  when  the  malady  is  clinically 
very  severe,  a  powerful  inhibitory  effect  is  exerted  upon  menstruation.  This 
is  especially  true  of  typhoid,  during  which  disease,  according  to  Osier  and 
McCrae,  amenorrhea  is  the  rule.  The  shorter  course  of  pneumonia  makes 
the  inhibitory  effect  less  conspicuous,  although  even  here  menstruation  is 
often  skipped.  Occasionally,  it  is  true,  menstruation  appears  to  be  in- 
creased in  amount  by  various  infectious  diseases,  as  in  certain  cases  of 
influenza  (Haken).  Such  an  effect,  however,  is  certainly  less  common  with 
infectious  diseases  than  the  occurrence  of  amenorrhea.  For  a  further  discus- 
sion of  this  subject  see  Chapter  XXV. 

Amenorrhea  Due  to  Constitutional  Diseases. —  Among  the  constitutional 
disorders  which  are  capable  of  producing  amenorrhea  may  be  mentioned 
chlorosis,  tuberculosis,  diabetes,  nephritis,  syphilis,  alcoholism,  drug  addic- 
tions, etc.  While  this  subject  is  more  elaborately  discussed  in  Chapter 
XXV,  mention  may  here  be  made  of  a  few  facts  bearing  on  this  relationship. 

Chlorosis. —  This  disease,  as  is  well  known,  is  especially  apt  to  develop  in 
young  girls  at  or  about  the  time  of  puberty.  This  fact,  together  with  the 
fact  that  it  is,  according  to  most  authors,  not  observed  in  males,  is  respon- 
sible for  the  tendency  to  associate  its  causation  with  a  hypoplasia  of  the 
reproductive  apparatus.  In  spite  of  the  classic  work  of  Virchow,  there  is 
no  indisputable  evidence  to  justify  this  belief.  The  principal  gynecological 
symptom  of  "  green  sickness,"  as  chlorosis  is  often  called,  is  scanty  men- 
struation or  complete  amenorrhea.  Absence  of  the  menses  is  extremely 
common,  Cabot  finding  it  in  120  of  a  series  of  387  cases. 

Tuberculosis. —  The  relation  of  tuberculosis  and  menstruation  is  of  the 


AMENORRHEA  173 

greatest  importance,  as  will  be  emphasized  elsewhere  (Chapter  XXV). 
For  the  present  we  may  say  that  amenorrhea  is  usual  in  advanced  cases  of 
phthisis,  and,  what  is  even  more  important,  that  it  is  frequently  a  symptom 
of  incipient  tuberculosis.  In  searching  for  the  cause  of  amenorrhea  in 
young  women,  one  must  always  bear  in  mind  the  possibility  of  an  early 
tuberculous  process  in  the  lungs. 

Other  constitutional  disorders. —  In  diabetes  and  nephritis,  amenorrhea  is 
a  frequent  concomitant.  The  relationship  is  apparently  not  at  all  a  direct 
one,  the  amenorrhea  merely  reflecting  the  general  lowering  of  vitality  so 
characteristic  of  aggravated  forms  of  these  diseases.  In  syphilis  also,  it 
sometimes  happens  that  menstruation  is  absent,  as  in  the  three  cases  reported 
by  Meirowsky  and  Frankenstein.  Other  constitutional  conditions  in  which 
amenorrhea  may  be  observed  are  lead  poisoning,  alcoholism,  and  morphinism. 

Influence  of  heredity. —  Under  this  head,  it  may  be  of  interest  also  to 
note  that  in  certain  cases  the  factor  of  heredity  has  been  credited  with  an 
influence  in  the  existence  of  amenorrhea.  A  rather  striking  case  of  this 
type  is  reported  by  Hoover  and  Marden.  Their  patient  was  a  Greek  woman 
of  forty  who  had  never  menstruated.  She  was  in  good  physical  condition, 
of  average  size  and  development,  and  rather  intelligent.  She  had  been 
married  at  the  age  of  15  and  had  had  11  children.  The  youngest  of  these 
was  four  years  old.  Her  grandmother  had  never  menstruated,  and  her 
mother  had  menstruated  only  once  or  twice  every  one  or  two  years.  The 
14  year  old  girl  of  the  patient  had  not  yet  menstruated.  She  herself  had 
never  observed  any  molimina,  having  always  "  lived  like  a  man." 

Amenorrhea  Due  to  Mental  and  Nervous  Disorders. —  In  practically  all 
forms  of  insanity,  amenorrhea  is  exceedingly  common.  This  is  especially 
true  of  the  depressive  forms  of  insanity,  such  as  melancholia.  When  men- 
struation is  present,  it  is  apt  to  be  scantier  than  normal,  and  to  exert  an 
unfavorable  influence  on  the  mental  malady.  The  same  facts  may  be  stated 
with  regard  to  the  allied  mental  conditions  associated  with  drug  addiction, 
especially  morphinism. 

Amenorrhea  Due  to  Disorders  of  the  Ductless  Glands. —  It  is  now  uni- 
versally accepted  that  the  ovary  is  an  internal  secretory  organ,  and  that  it  is 
intimately  bound  up  with  all  of  the  so-called  ductless  glands.  It  is  therefore 
almost  a  truism  to  say  that  menstruation  is  influenced  by  derangements  in 
practically  any  part  of  the  ductless  gland  chain.  Aside  from  the  ovary 
itself,  amenorrhea  is  most  likely  tO'  be  associated  with  secretory  derange- 
ments of  two  of  the  ductless  glands,  viz.,  the  thyroid  and  the  pituitary. 

Thyroid. —  There  is  considerable  difference  of  opinion  as  to  the  influence 
of  thyroid  diseases  upon  the  menstrual  function.  In  some  cases  of  hyper- 
thyroidism, it  is  apparently  unaltered,  in  others  it  seems  to  be  decreased, 
and  in  still  others  it  appears  to  be  increased.  The  same  statements  may  be 
made  with  regard  to  the  opposite  condition  of  hypothyroidism.  This  ap- 
parent paradox  is  not  difficult  to  comprehend  when  one  bears  in  mind  the 
pluriglandular  nature  of  most  ductless  gland  disorders.     Speaking  gener- 


174  MENSTRUATION  AND  ITS  DISORDERS 

ally,  it  may  perhaps  be  said  that  amenorrhea,  with  which  we  are  concerned 
in  this  chapter,  is  more  frequent  in  hyperthyroidism  than  in  hypothyroidism, 
bearing  in  mind  that  there  are  many  exceptions  to  this  general  rule. 

Pituitary. —  The  adiposogenital  dystrophy  of  Frohlich.  The  form  of 
pituitary  derangement  which  is  most  frequently  associated  with  amenorrhea 
is  that  which  is  due  to  hypopituitarism,  and  which  is  clinically  associated 
with  obesity. 

Among  the  causes  of  amenorrhea  given  by  almost  all  text  books  on 
gynecology  is  adiposity.  The  relation  which  exists  between  obesity  and 
absence  of  the  menstrual  flow  is  an  interesting  one,  and  has  been  the  sub- 
ject of  much  discussion,  especially  within  recent  years.  Formerly  it  was 
believed  by  some  that  the  obesity  in  these  cases  was  the  cause  of  the  amenor- 
rhea, while  the  exact  reverse  was  held  by  others.  AVithin  recent  years,  how- 
ever, an  entirely  new  light  has  been  thrown  upon  this  relationship  by  the  in- 
teresting work  of  Paulesco,  Gushing,  Frohlich,  and  others,  upon  the  pituit- 
ary body.  It  has  been  found  that  in  certain  cases  of  disease  of  this  body 
there  is  produced  an  interesting  grouping  of  symptoms,  the  most  conspicu- 
ous of  which  are  obesity  and  sexual  hypoplasia.  In  women  the  physiological 
manifestation  of  this  hypoplasia  is  amenorrhea. 

It  was  furthermore  shown  that  this  same  syndrome  —  the  adiposogenital 
syndrome  of  Frohlich  —  could  be  produced  experimentally  in  animals  by 
partial  removal  of  the  hypophysis.  Many  such  experiments  are  reported  by 
Gushing  and  others.  Since  disturbance  of  the  pituitary  can  thus  be  shown 
to  be  capable  of  producing  amenorrhea  and  obesity,  it  seems  reasonable  to 
assume  that  both  these  symptoms,  when  associated  clinically,  are  produced 
by  the  same  underlying  cause,  and  that  this  cause  is  probably  to  be  sought  in 
some  disturbance,  functional  or  otherwise,  in  the  pituitary  body.  For  a 
further  discussion  of  this  subject,  see  Ghapter  XXIV. 

Significance  of  Amenorrhea  as  a  Symptom. —  From  the  above  dis- 
cussion of  the  etiology  of  amenorrhea,  it  appears  that  it  must  be  regarded  as 
only  a  symptom  of  any  one  of  a  large  number  of  underlying  causes.  In 
spite  of  the  fact  that  it  is  only  a  symptom,  it  is  often  in  itself  a  source  of 
grave  concern  to  the  patient.  A  very  prevalent  belief  among  the  laity  is 
that  absence  of  menstruation  will  lead  to  consumption  —  that  the  patient 
will  "  go  into  decline."  Every  practicing  physician  encounters  this  notion 
time  and  time  again. 

This  idea  is  greatly  strengthened,  in  the  minds  of  the  laity,  by  the  fact 
that  many  amenorrheic  patients  are  anemic,  and  that  they  frequently  suffer 
with  functional  disorders  of  the  heart  and  stomach.  Furthermore,  it  is  true 
that  menstruation  usually  ceases  in  the  late  stages  of  tuberculosis.  The 
inference  is  thus  drawn  that  amenorrhea  stands  in  some  specific  relationship 
to  consumption.  While  this  is  incorrect,  it  must  not  be  forgotten  that  in 
certain  cases  of  tuberculosis,  especially  in  young  women,  amenorrhea  is  a 
very  early  symptom. 

Is  Amenorrhea  Detrimental  to  Health?  —  The  question  is  frequently 


AMENORRHEA  175 

asked  as  to  whether  the  existence  of  amenorrhea  is  in  any  way  detrimental 
to  the  general  health.  From  what  has  already  been  said  it  will  seem  that,  if 
anything,  its  inlluence  is  apparently  in  some  cases  conservative,  as  when  it 
occurs  in  conditions  of  lowered  vitality.  When  its  causation  is  more 
obscure,  and  especially  when  the  general  health  of  the  patient  does  not  seem 
to  be  deteriorated,  no  such  protective  influence  can  be  assumed.  There  is  no 
evidence,  however,  to  show  that  the  non-occurrence  of  menstruation  in  such 
cases  is  in  itself  detrimental  to  the  health  of  the  woman. 

The  old  theory  that  menstruation  is  a  cleansing  process,  ridding  the  body 
of  poisonous  and  obnoxious  materials,  has  led  some  to  believe  that  amenor- 
rhea allows  a  retention  of  such  products,  and  that  it  is  therefore  injurious  to 
the  woman's  health.  In  other  words,  it  is  believed  by  some  that  amenorrhea 
may  cause  a  "  menorrhemia "  analogous  to  the  uremia  which  follows 
anuria.  As  already  stated,  however,  no  scientific  evidence  has  been  adduced 
in  support  of  such  a  belief,  and,  indeed,  clinical  evidence  is  quite  opposed 
to  it. 

Symptoms  Which  May  Be  Associated  with  Amenorrhea. —  In  cer- 
tain cases,  absence  of  menstruation  is  associated  with  mild  neuroses  or 
psychoses,  and  occasionally  with  a  condition  of  melancholia.  In  such  cases, 
however,  it  seems  highly  probable  that  these  manifestations  are  due  to  worry 
and  anxiety  over  the  non-appearance  of  the  menses  rather  than  to  any  direct 
effect  of  the  amenorrhea  itself. 

In  some  patients  headache  is  complained  of,  this  being  usually  much 
accentuated  at  the  time  of  the  menstrual  periods.  Asthma  has  been  de- 
scribed as  occurring  in  some  cases  of  amenorrhea,  but  I  have  never  observed 
such  a  case.  In  rare  cases  more  serious  symptoms  may  be  noted,  although 
it  is  a  question  as  to  how  far  these  may  be  directly  attributed  to  the  amenor- 
rhea. Gemmell,  for  example,  cites  the  case  of  a  girl  of  sixteen  whose 
menses  were  normal  up  to  the  time  she  went  to  boarding  school,  when  they 
ceased.  In  about  one  month  she  suddenly  became  blind  in  one  eye.  At 
the  end  of  three  months  she  was  practically  blind  in  both.  This  blindness 
was  caused  by  hemorrhages  into  the  vitreous.  After  this  she  received  treat- 
ment to  bring  on  her  periods,  and  at  the  time  of  the  report  had  regained  the 
sight  of  one  eye.  The  presence  of  the  hemorrhages  would  seem  to  elim- 
inate the  possibility  of  the  blindness  being  hysterical  in  origin.  It  is  a 
question,  however,  whether  these  hemorrhages  are  not  to  be  looked  upon 
as  representing  a  vicarious  menstruation,  in  which  case  the  resulting  blind- 
ness could  scarcely  be  attributed  to  the  amenorrhea  in  itself,  except  in  so 
far  as  this  was  responsible  for  the  vicarious  phenomenon. 

Rosenberger  speaks  of  the  occurrence  of  optic  nerve  atrophy  and  other 
ocular  conditions  in  amenorrhea,  explaining  them  as  due  to  pressure  on  the 
optic  chiasm  by  an  enlarged  anterior  lobe  of  the  pituitary  body.  He  sug- 
gests syphilis  as  a  possible  cause.  Such  occurrences,  however,  must  be 
exceedingly  rare. 

In  some  cases  of  amenorrhea  the  normal  discharge  of  menstrual  blood  is 


176  MENSTRUATION  AND  ITS  DISORDERS 

rq)]aced  by  a  white  mucous  discharge,  the  menstrual  leucorrhea  or  "  fluor 
albus."  In  other  instances,  again,  the  patient  retains  a  "  menstrual 
memory,"'  so  that  even  though  the  menses  are  absent  there  is  a  certain 
amount  of  local  or  general  disturbance  at  the  time  of  the  menstrual  periods. 
Finally,  in  perhaps  the  majority  of  cases,  the  woman  experiences  no  subjec- 
tive signs  whatsoever  of  the  menstrual  period. 

When  the  menses  are  absent  as  a  result  of  mechanical  occlusion  of  the 
genital  canal,  on  the  other  hand,  menstrual  molimina  are  perceived  by  the 
patient  each  month.  This  is  only  what  might  be  expected,  inasmuch  as  the! 
menstrual  blood  is  given  off  by  the  endometrium  regularly.  The  gradual 
accumulation  of  the  menstrual  discharge  behind  the  point  of  obstruction 
results  sooner  or  later  in  the  formation  of  a  tumor  mass,  which  is  productive 
of  further  pressure  symptoms  (see  Chapter  XIX). 

The  suppression  of  menses  which  is  so  often  brought  about  by  wetting  of 
the  feet  or  chilling  of  the  body  after  the  menstrual  congestion  has  already 
set  in  is  also  not  infrequently  associated  with  local  and  even  general  discom- 
fort. Heaviness  and  bearing  down  in  the  pelvis  are  oft^n  complained  of, 
and  sometimes  a  slight  febrile  reaction  is  observed,  together  with  headache 
and  malaise. 

In  amenorrhea  associated  with  diseases  of  various  kinds  there  are  no 
symptoms  referable  to  the  amenorrhea  itself,  the  clinical  picture  pertaining 
altogether  to  the  underlying  disease. 

In  cases  of  more  obscure  causation,  such  as  those  due  to  change  of  climate, 
or  to  disturbances  in  the  ductless  gland  system,  the  occurrence  of  the 
amenorrhea  appears  to  entail  no  symptoms,  other  than  such  nervous  or 
mental  symptoms  as  are  to  be  explained  by  worry  over  the  failure  of  the 
menses  to  appear.  The  same  innocuousness  is  characteristic  of  the  physio- 
logical amenorrhea  of  puberty,  the  menopause,  pregnancy  and  lactation. 

Diagnosis  of  Cause. —  As  far  as  the  mere  existence  of  amenorrhea  is 
concerned,  no  diagnostic  problem  is  presented.  The  aim  in  all  cases  of 
amenorrhea,  however,  should  be  to  determine  the  cause  of  the  condition. 
In  some  cases  this  will  be  very  easy,  in  others  difficult  or  perhaps  impossible. 

The  diagnosis  of  retention  of  menses  due  to  mechanical  obstruction  of 
the  genital  canal,  either  congenital  or  acquired,  can  usually  be  made  without 
difficulty  by  examination  of  the  reproductive  organs.  While  such  an  exam- 
ination should  always  be  avoided  in  the  case  of  young  unmarried  women, 
it  is  indicated  in  cases  of  primary  amenorrhea,  with  well  marked  menstrual 
molimina  or  other  symptoms  which  suggest  gynatresia.  The  examination 
should  preferably  be  made  under  anesthesia. 

The  diagnostic  problem  presented  by  cases  of  physiological  amenorrhea 
is  often  anything  but  simple,  owing  to  the  frequent  difficulty  of  distinguish- 
ing between  the  simple  amenorrhea  of  puberty  or  the  menopause  on  the  one 
hand,  and  the  amenorrhea  of  pregnancy  on  the  other  hand.  Especially  at 
or  near  the  age  of  the  menopause  is  this  problem  apt  to  arise.  It  is  some- 
times rendered  difficult  by  the  adiposity  often  accompanying  the  climacteric 


AMENORRHEA  177 

and  by  the  fact  that  subjective  symptoms  of  pregnancy  are  apt  to  coexist, 
thus  bringing  about  a  striking  mimicry  of  pregnancy  (pseudocyesis).  Even 
with  the  most  careful  examination,  it  is  not  always  possible  to  make  a 
positive  diagnosis  at  the  first  examination. 

With  regard  to  amenorrhea  due  to  disorders  of  the  ductless  glands,  it  is 
possible,  in  a  certain  number  of  cases,  to  fix  upon  such  a  causation  from  the 
existence  of  definite  symptoms  of  disturbed  function  in  the  thyroid,  pituitary, 
or  other  internal  secretory  glands.  The  most  clear  cut  cases  of  this  group 
are  those  of  the  tpye  of  adiposogenital  dystrophy.  A  presumptive  diagnosis 
of  the  latter  may  be  made  when  absence  of  the  menses  is  associated  with 
rather  sudden  and  perhaps  very  great  increase  in  weight,  without  any  other 
apparent  cause.  Occasionally,  of  course,  conditions  may  be  present  which 
make  it  possible  to  arrive  at  a  positive  diagnosis,  as  in  the  case  of  pituitary 
or  suprarenal  tumors.  Unfortunately,  however,  it  is  difficult  in  many 
instances  to  make  more  than  a  presumptive  diagnosis. 

A  word  of  caution  must  be  uttered  against  deciding  too  quickly  that  a 
case  of  amenorrhea  is  due  to  ductless  gland  derangement,  when  perhaps  a 
more  thorough  examination  would  reveal  some  much  more  tangible  cause 
for  the  condition,  such,  for  example,  as  incipient  tuberculosis. 

Treatment  of  Amenorrhea. —  Physiological  amenorrhea,  of  course, 
requires  no  treatment.  The  treatment  of  pathological  amenorrhea  may  be 
considered  under  the  following  heads:  (i)  treatment  of  the  underlying 
cause;  (2)  general  treatment ;  (3)  medicinal  treatment ;  (4)  organotherapy. 

Treatment  of  Underlying  Cause. —  It  goes  almost  without  saying 
that  whenever  it  is  possible  to  remove  the  cause  of  amenorrhea,  this  is  the 
fundamental  step  in  the  treatment.  When,  for  example,  the  menses  do  not 
appear  because  of  an  obstruction  in  the  genital  canal,  the  indication  is  to 
relieve  the  obstruction  (see  Chapter  XIX).  Again,  when  amenorrhea  is 
merely  an  incident  in  the  course  of  some  disease,  either  acute  or  chronic,  no 
treatment  directed  to  the  relief  of  the  amenorrhea  itself  is  indicated.  In 
other  words,  since  amenorrhea  is  usually  a  symptom  of  some  underlying 
pathological  state,  an  efifort  should  always  be  made  to  discover  the  causative 
condition  and  treat  it.  What  we  shall  have  to  say  in  the  following  para- 
graphs has  to  deal  largely  with  those  very  numerous  cases  in  which  the 
cause  is  not  definitely  ascertainable  or  in  which  no  specific  treatment  seems 
possible. 

General  Measures. —  In  all  cases  of  amenorrhea  it  is  extremely  im- 
portant to  impress  upon  the  patient  the  necessity  of  a  proper  hygienic 
regime.  Opeii  air  recreation,  such  as  that  afforded  by  walking,  riding, 
boating,  etc.,  is  of  great  importance  when  there  exist  no  contra-indications. 
It  is  scarcely  necessary  to  say  that  such  active  forms  of  exercise  would  be, 
to  say  the  least,  very  inadvisable  in  the  amenorrhea  of  early  phthisis.  In 
the  latter  form  of  the  disorder  the  need  of  fresh  air,  combined  with  rest,  is 
of  the  greatest  Importance.  The  diet  should  be  of  nutritious  and  easily 
digestible  food  stuffs,  including  a  goodly  portion  of  fruits  and  vegetables; 


178  MENSTRUATION  AND  ITS  DISORDERS 

practically  all  of  which  are  rather  rich  in  iron.  Constipation  should  be 
relieved  when  present,  preferably  by  some  one  of  the  vegetable  purgatives. 

Much  stress  must  be  laid  upon  the  importance  of  avoiding  ovenvork, 
either  physical  or  mental.  Such  sociological  aspects  of  the  problem  are  not 
always  easy  to  correct,  but  they  are  of  great  importance.  Mental  fatigue, 
such  as  is  seen  in  so  many  girls  in  our  modern  schools  and  colleges,  is  per- 
haps even  more  important  in  the  causation  of  amenorrhea  than  is  physical 
overwork. 

Among  other  general  measures  which  are  often  of  value  in  the  treatment 
of  amenorrhea  may  be  mentioned  hot  baths  and  hot  drinks.  This  is  espe- 
cially true  in  the  sudden  suppression  of  the  menses  which  follows  wetting  of 
the  feet  or  chilling  of  the  body.  In  some  of  these  cases  the  flow  may  be 
reestablished,  although  more  frequently  it  remains  absent  until  the  time  of 
the  next  period. 

Medicinal  Treatment. —  In  certain  forms  of  amenorrhea  treatment 
by  drugs  is  of  very  great  value,  in  others  it  is  useless.  The  two  classes  of 
drugs  which  are  most  extensively  utilized  in  the  treatment  of  amenorrhea 
are  the  hcmatinics  and  the  emmenagogues.  The  former  answer  a  real  indi- 
cation in  many  cases  of  amenorrhea  and  it  is  therefore  not  surprising  that 
they  yield  successful  results  far  more  frequently  than  do  the  emmenagogues. 

The  most  important  indication  for  the  administration  of  hematinics  in 
amenorrhea  is,  of  course,  in  those  cases  which  are  clearly  secondary  to 
chlorosis  and  other  forms  of  anemia. 

Iron  in  the  Treatment  of  Amenorrhea. —  No  drug  can  fully  take  the 
place  of  iron  in  the  treatment  of  the  latter  group  of  cases.  It  may 
be  administered  in  various  forms,  and  in  combination  with  other  hematinics 
or  general  tonics.  Perhaps  the  most  popular  method  of  giving  iron  is  in 
the  form  of  the  well-known  Blaud's  pill  (pil.  ferri  carbonat.),  which  may 
be  prescribed  in  doses  of  one  or  two  pills  after  each  meal.  The  dried  sul- 
phate of  iron  is  also  frequently  employed,  in  doses  of  one  or  two  grains 
three  times  a  day.  Where  there  is  a  tendency  toward  constipation,  as  there 
is  so  apt  to  be  during  the  course  of  medication  by  iron,  it  is  often  advisable 
to  combine  the  iron  with  aloes  or  nux  vomica.  Arsenic  also  may  be  admin- 
istered together  with  the  iron.  I  have  personally  often  made  use  of  the 
following  prescription : 

Ferri  exsiccati   gr,  xlv 

Arseni  trioxid gr.  | 

Strychnin,  sulphat gr.  ss. 

M  et  div.  in  caps.  no.  xxx. 

Sig.     One  capsule  after  each  meal. 

Another  convenient  and  effective,  though  less  agreeable,  method  of  ad- 
ministering iron  is  in  the  form  of  the  tincture  of  chlorid  (tinct.  ferri 
chlorid.).  This  may  be  given  in  increasing  doses,  beginning  with  seven  or 
eight  minims  well  diluted,  and  taken  through  a  glass  tube.     The  dose  may 


AMENORRHEA  179 

gradually  be  increased  up  to  twenty  or  even  thirty  minims.  In  connection 
with  this  preparation,  it  is  worth  remembering  that,  like  wine,  it  improves 
with  age,  so  that  the  best  results  are  not  to  be  obtained  with  very  fresh 
preparations. 

The  syrup  of  the  iodid  of  iron  (syr.  ferri  iodid.)  is  also  frequently  em- 
ployed, especially  in  girls  at  or  near  the  age  of  puberty.  It  may  be  given 
in  doses  of  from  twenty  to  thirty  minims  three  times  a  day.  The  citrate, 
the  phosphate,  and  the  tartrate  have  all  been  employed  by  various  clinicians. 
Herman  recommends  the  following  formula : 

Ferri  et  ammon.  citrat 3  i 

Potass  carb gr.  xxiv 

Spir.  chloroform    3  i  . 

Aq.  dest.  q.s.ad §  vi 

M 

Sig.     One  dessertspoonful  after  each  meal. 

In  addition  to  the  various  preparations  of  iron  already  mentioned,  all  of 
which  are  official,  attention  may  be  called  to  the  fact  that  the  National 
Formulary  offers  a  number  of  preparations,  chiefly  elixirs,  for  the  con- 
venient and  agreeable  administration  of  iron.  Among  them  I  may  mention 
the  following,  the  average  dose  of  all  being  one  dram :  Elixir  ferri  hypo- 
phosphitis,  elixir  ferri  lactatis,  elixir  ferri  phosphatis,  the  well-known 
elixir  ferri,  quininae  et  strychniae,  syrup,  ferri  hypophosphitis  and 
syrup,  lactophosphatis.  Mention  may  also  be  made  of  tinct.  ferri  citro- 
chlorid,  the  average  dose  of  which  is  ten  minims,  and  of  the  pil.  ferri 
compositae. 

No  matter  what  form  of  iron  is  resorted  to  in  the  treatment  of  amenor- 
rhea, its  use  should  be  kept  up  for  a  long  time,  rarely  less  than  three  months, 
and  often  much  longer.  Failure  to  restore  the  menstrual  function  in  cases 
of  chlorosis  is  usually  due  either  to  insufficient  dosage  or  to  too  early 
cessation  of  the  treatment. 

Arsenic. —  Next  to  iron,  the  most  valuable  of  the  hematinic  drugs  is 
arsenic.  In  my  experience,  however,  it  is  distinctly  inferior  to  iron  in  the 
treatment  of  the  amenorrhea  of  chlorosis.  When  the  anemia  is  not  of  the 
chlorotic  type,  arsenic  is  often  a  very  valuable  drug.  It  is  usually  adminis- 
tered in  the  form  of  Fozvler's  solution  (liq.  potassii  arsenit.)  in  gradually 
increasing  doses,  beginning  with  three  minims  well  diluted  in  water  three 
times  a  day,  and  increasing  by  the  addition  of  one  minim  to  the  dose  every 
second  or  third  day  until  the  point  of  physiological  saturation  is  reached. 
This,  as  is  well  known,  usually  makes  itself  evident  by  supraorbital  neuralgia, 
watering  of  the  eyes  and  nose,  puffiness  of  the  eyelids,  or  gastro-intestinal 
irritation. 

Questionable  Value  of  Emmenagogues. —  The  use  of  emmenagogues 
in  the  treatment  of  amenorrhea  can  scarcely  be  looked  upon  as  a  rational 
therapeutic  measure,  although  it  is  practiced  quite  generally.     I  confess  to 


180  MENSTRUATION  AND  ITS  DISORDERS 

an  extreme  skepticism  concerning  the  results  of  such  medication.  Among 
the  laity,  especially,  there  is  a  widespread  belief  that  it  is  a  simple  matter 
for  the  physician  to  prescribe  medicines  to  "  bring  on  "  the  menstrual  flow. 
Bearing  in  mind  the  varied  and  often  obscure  etiology  of  amenorrhea,  and 
the  fact  that  in  many  instances  it  appears  to  be  a  somewhat  protective 
phenomenon,  the  fallacy  of  such  a  notion  is  obvious. 

Some  one  has  compared  the  menstrual  mechanism  to  the  works  of  a  clock, 
remarking  that  "  if  the  works  are  in  good  order,  the  clock  will  strike  regu- 
larly." With  amenorrhea,  therefore,  the  indication  is  clearly  to  put  the 
entire  menstrual  mechanism  in  good  order  rather  than  to  attempt  by  means 
of  emmenagogues  to  correct  a  condition  which,  to  say  the  least,  may  be 
perfectly  harmless.  In  view  of  these  personal  convictions,  I  shall  do  little 
more  than  mention  a  few  of  the  drugs  which  have  been  credited  with  more 
or  less  powerful  emmenagogue  properties. 

Perhaps  the  best  known  of  these  is  manganese,  which  is  employed  either 
in  the  form  of  the  dioxid  (mangani  dioxidum)  or  of  the  permanganate  of 
potash  (potassii  permanganat).  Many  prefer  the  former,  which  is  given 
in  doses  of  from  two  to  five  grains,  while  the  permanganate  is  given  in 
smaller  doses,  one  half  to  two  grains. 

The  following  prescription,  which  would  seem  to  combine  the  good  efifects 
of  iron,  arsenic,  and  manganese,  has  been  recommended  by  Kelly : 

Ferri  sulphat gr.  ii 

Acidi  arsenos gr.  1/40 

Mangani  dioxid gr.  iii 

M.  et  ft.  pil.  Mitte  tales  100. 
Sig.     One  pill  three  times  a  day. 

Another  drug,  which  was  first  used  by  the  French,  and  which  has  enjoyed 
a  wide  vogue  as  an  emmenagogue,  is  apiol  (oil  of  parsley),  which  is  admin- 
istered in  capsule  in  doses  of  from  three  to  ten  minims  after  each  meal.  Its 
administration  should  be  begun  several  days  before  the  usual  time  for 
menstruation. 

An  emmenagogue  effect  is  also  ascribed  to  many  of  the  vegetable  purga- 
tives, and  especially  to  aloes.  This  drug  has  in  the  past  been  widely  used 
for  this  purpose.  Marshall  Hall  speaks  of  it  as  being  just  as  certain  in  many 
cases  as  quinin  is  in  the  treatment  of  malaria.  It  is  frequently  combined 
with  iron  and  perhaps  nux  vomica,  as  mentioned  above.  The  official  pill  of 
aloes  and  iron  fpilul.  aloes  et  ferri)  is  also  not  infrequently  used,  in  doses 
of  from  one  to  four  pills.  The  following  pill,  containing  aloes,  was  recom- 
mended by  Goodell : 

Extract!  aloes 5  i 

Ferri  sulphatis  exsiccati 3  ii 

Asafetidae 3  iv 

Fiant  pilulae  no.  c. 

Sig.     From  one  to  three  pills  three  times  a  day  at  each  period. 


AMENORRHEA  181 

There  is  little  doubt  that  aloes  causes  pelvic  hyperemia, "  but  whether  it 
has  any  directly  emmenagogue  effect  is  open  to  question. 

Mention  may  also  be  made  of  asafetida,  guaiacum,  borax,  cantharides, 
and  all  the  ecbolics,  especially  ergot  and  quinin.  The  use  of  fuchsin  has 
been  recommended  by  Mondy,  who  reports  a  case  of  amenorrhea  of  four 
years  standing  successfully  treated  by  this  drug  given  in  pill  form  three  times 
a  day. 

The  following  drugs  have  also  been  used  in  the  treatment  of  amenorrhea, 
although  their  efifect  is  very  uncertain:  Santonin  (gr.  ii  or  gr.  iii  t.i.d.)  ; 
oleum  sabinae  (m  iii  to  m  v  t.i.d.)  ;  oleum  rutae  (m  iii  to  m  v  t.i.d.)  ; 
oleum  tanaceti  (m  iii  to  m  v  t.i.d.)  ;  tinctura  cantharidis  (m  xx  to  m  xxx 
t.i.d.)  ;  tinctura  hellebori  nigri  (m  xx  to  m  xl  t.i.d.).  For  reasons  which 
have  already  been  discussed,  my  own  feeling  is  that  it  is  not  good  thera- 
peutics to  try  to  "  bring  on  the  flow  "  with  such  drugs. 

Organotherapy  of  Amenorrhea. —  A  discussion  of  this  subject  will  be 
found  in  Chapter  XXVI. 

XVIII 

LITERATURE 

Brown.     A  Note  on  Normal  Menstruation  with  Absence  of  Body  of  Uterus. 

Lancet,  1909,  i,  1456. 
BuRFORD.     Amenorrhea  Associated  with  Alcoholism.     Brit.   M,  J.,   1888,   i, 

1383. 

Carstens.  Silver  Stem  Pessary  Treatment  of  Amenorrhea  and  Dysmenor- 
rhea.    Med.  and  Surg.,  1917,  i,  617. 

CoHN.  Zur  Casuistik  der  Amenorrhoe  bei  Diabetus  MelHtus  und  Insipidus. 
Zeitsch.  f.  Geb.  u.  Gyn.,  1887-88,  14,  194. 

DoRAN.     Chlorosis  and  Amenorrhea.     Trans.  Obst.  Soc.  Lond.,  1889,  31,  119. 

Emmett,  T.  a.     Text  Book  of  Gynecology.     Philadelphia,  1880. 

Friedrich.     Amenorrhoe  und  Phthisis.     Arch.  f.  Gyn.,  1914,  loi,  376. 

Fries.     Behandlung  der  Amenorrhoe.     Deutsch.  Med.  Wchnsch.,  191 3,  39,  675. 

Frohlich.  Fin  Fall  von  Tumor  der  Hypophysis  Cerebri  ohne  Akromegalie. 
Wien.  Klin.  Rundschau,  1901,  15,  883. 

Fromme.  Zur  Behandlung  der  Amenorrhoe.  Zentralb.  f.  Gyn.,  1912,  36, 
1366. 

Herman.  Lectures  on  Diagnosis  and  Treatment  of  the  Conditions  Causing 
Amenorrhea.     Med.  Press  and  Circ,  1893,  n.s.,  55,  269;  295;  321 ;  351 ; 

375- 
Hofstatter.     Zur  Behandlung  der  Amenorrhoe.     Zentralb.  f.  Gynak.,  1912, 

36,  1536. 
Hoover  and  Marden.     Case  of  Complete  Amenorrhea,  with  Heredity  as  a 

Probable  Etiological  Factor.     Surg.,  Gyn.  and  Obst.,  191 1,  12,  288. 
Kohler.     Ueber  Kriegsamenorrhoe.     Zentralb.  f.  Gyn.,  1919,  43,  358. 
LoMER.     Adipositas  bei  Amenorrhoe.     Centralb.  f.  Gyn.,  1893,  17,  641. 
Mitchell.     Report  of  a  Case  of  Complete  Non-menstruation,     Brit.  Gyn. 

Jour.,  1896,  46,  179. 


182  MENSTRUATION  AND  ITS  DISORDERS 

Ohrenstein.     Beitrag     zur     Behandlung     der     Amenorrhoe.     Wien.     Med. 

Wchnsch.,  1914,  64,  2013. 
RiECK.     Eine  noch  Unbekannte  Form  Mechanisch  Bedingter  Amenorrhoe  und 

ihre  Operative  Behandlung.     Miinch.  Med.  Wchnsch.,  1909,  56,  559. 
RosENBERGER.     Zur    Atiologie    der    Amenorrhoe.      Miinch.    Med.    Wchnsch., 

191 1,  58,926. 
RoTHROCK.     Association  of  Obesity  with  Amenorrhea  and  Sterihty.     St.  Paul 

M.  J.,  1908,  10,  70. 
ScHiFFMAN.     Tuberkulose,  Uterusatresia,  und  Amenorrhoe.     Arch.  f.  Gyn., 

1914,  103,  I. 
Simpson.     Clinical  Lecture  on  Amenorrhea.     Practitioner,  1898,  61,  137. 
Spencer.     Absence  of  Fallopian  Tubes  and  of  Menstruation.     Brit.  M.  J., 

1911,  I,  189. 
Stephenson.     On  Relation  between  Chlorosis  and  Menstruation.     Tr.  Obst. 

Soc.  London,  1889,  31,  104. 


CHAPTER  XIX 

GYNATRESIA  AND  RETENTION  OF  THE  MENSTRUAL  DISCHARGE 

General  Conditions. —  By  gynatresia  is  meant  a  closure  of  some  por- 
tion of  the  genital  tract.  In  by  far  the  largest  number  of  cases  the  atresia 
is  noted  in  the  lower  portion  of  the  vaginal  canal.  While  the  condition  often 
causes  no  symptoms  before  puberty,  it  may  be  of  serious  import  when 
menstruation  has  been  inaugurated.  The  immediate  effect  of  gynatresia  in 
cases  of  the  latter  type  is  to  cause  a  retention  of  the  menstrual  flow.  Clini- 
cally, the  condition  is  commonly  considered  to  be  amenorrhea,  although  as  a 
matter  of  fact  menstruation  really  goes  on  approximately  as  in  the  normal 
woman,  with  the  exception  that  the  menstrual  discharge  is  prevented  by  the 
obstruction  from  reaching  the  exterior  (Chapter  XVIII). 

Types  of  Gynatresia. —  Two  general  types  of  this  condition  may  be 
described,  the  congenital  and  the  acquired.  Since  there  are  now  many  who 
believe  that  even  the  so-called  congenital  cases  are  really  due  to  infection 
and  inflammation,  it  has  been  proposed  that  the  terms  primary  and  secondary 
be  applied  to  the  two  groups  (Brothers). 

Causes  of  Primary  or  Congenital  Gynatresia. —  The  former  view 
was  that  practically  all  the  so-called  congenital  cases  are  due  to  a  defect  of 
development  in  some  portion  of  the  miillerian  ducts.  According  tO'  Dohrn, 
these  ducts  unite  at  about  the  seventh  week  of  embryonal  life,  while  by  the 
end  of  the  third  month  the  dififerentiation  into  uterus  and  vagina  is  already 
evident  (Kussmaul).  The  hymen,  it  may  be  added,  does  not  appear  until 
about  the  nineteenth  week.  The  genital  canal  is  thus,  under  normal  circum- 
stances, completely  developed  at  about  the  fifth  month. 

Gynatresia  may  occur  when  the  miillerian  ducts  have  fully  united  or  when 
they  have  remained  separate  throughout  a  greater  or  less  extent  of  their 
course.  Of  145  cases  of  primary  menstrual  retention  collected  by  Brothers, 
there  was  a  single  genital  canal  in  80,  as  compared  with  60,  in  which  the 
canal  was  double.  Practically  any  of  the  well  known  forms  of  malformed 
uterus  may  be  associated  with  gynatresia,  such  as  uterus  didelphys,  uterus 
bicornis  or  unicornis,  uterus  biseptatus,  etc.  The  vagina  may  be  single 
or  double. 

The  Nagel-Veit  Theory. —  As  already  intimated,  the  theory  that  many 
of  the  obstructions  which  may  occur  in  the  vaginal  canal  are  congenital  has 
been  vigorously  disputed.  Nagel  believes  that  they  are  all  acquired.  Fur- 
thermore, he  does  not  believe  that  congenital  absence  of  the  vagina  can  be 
associated  with  normal  development  of  the  uterus,  tubes,  and  ovaries,  and 

183 


184  MENSTRUATION  AND  ITS  DISORDERS 

he  asserts  that  when  the  vagina  is  atretic  in  otherwise  normal  cases,  the 
defect  is  due  to  adhesion  of  opposing  vaginal  surfaces  as  a  result  of  loss  of 
the  epithelial  covering.  These  changes  may  occur  as  a  result  of  inflamma- 
tions in  very  early  life,  or  even  before  birth. 

Veit  not  only  supports  Nagel's  views  as  to  the  acquired  nature  of  these 
abnormalities,  but  goes  a  step  further.  He  believes  that  when  a  hema- 
tosalpinx is  present  with  gynatresia,  the  evidence  is  complete  that  there 
exists  some  infection  of  the  genital  tract,  and  that  the  condition  is  acquired 
and  not  congenital.  It  is  the  infection  present  in  these  cases  which 
causes  an  inflammatory  closure  of  the  abdominal  end  of  the  tube,  thus 
permitting  the  development  of  the  hematosalpinx. 

Imperforate  Hymen. —  The  most  common  congenital  obstruction  is 
usually  looked  upon  as  an  imperforate  hymen,  although  the  studies  of  Bell 
indicate  that  the  obstructing  membrane  in  this  group  of  cases  is  not  the 
hymen,  but  an  "  imperforation  "  of  the  lower  end  of  the  vagina.  Bell 
credits  Matthews  Duncan  with  having  first  called  attention  to  this  fact. 
Histological  study  of  the  membrane  in  these  cases  shows  that,  while  the 
outer  surface  is  covered  with  stratified  squamous  epithelium,  similar  to  that 
of  the  vulva,  the  inner  surface  is  often  covered  with  columnar  epithelium. 
This,  in  Bell's  opinion,  proves  that  the  membrane  cannot  be  the  hymen,  for 
the  latter  is  covered  on  both  surfaces  by  stratified  squamous  epithelium. 

If  the  Nagel-Veit  theory  be  correct,  the  origin  of  these  cases  is  to  be 
sought  in  an  acquired  factor  of  one  form  or  another,  although  they  have  in 
the  past  been  quite  generally  looked  upon  as  congenital.  That  at  least  some 
of  them  are  of  acquired  origin  admits  of  no  doubt.  Veit,  for  example, 
reported  a  case  of  complete  atresia  of  the  hymen  in  a  woman  who  was 
pregnant  at  term,  and  also  a  case  in  which  the  woman  had  previously  men- 
struated regularly,  over  a  period  of  several  years.  Obstruction  by  an 
imperforate  hymen  results  first  in  distention  of  the  vagina  with  blood 
(hematocolpos).  This  is  followed  in  turn  by  distention  of  the  cervix 
(hematotrachelos),  then  of  the  uterus  (hematometra),  and  finally  of  the 
tubes  (hematosalpinx).      (Fig.  29.) 

Other  Forms  of  Obstruction. —  Much  less  frequently  the  obstructing 
membrane  may  be  located  higher  in  the  vagina,  or  perhaps  in  the  cervix. 
Complete  absence  of  the  vagina,  of  congenital  origin,  cannot,  according  to 
Nagel,  exist  with  normal  pelvic  organs,  and  cannot  therefore  be  a  cause  of 
hematometra.  This  view  would  seem  to  be  corroborated  by  the  findings  in 
six  cases  of  congenital  absence  of  the  vagina  which  I  recently  reported.  In 
all  of  them  the  uterus  was  absent. 

Secondary  or  Acquired  Gynatresia. —  In  the  majority  of  cases  sec- 
ondary gynatresia  is  due  to  an  inflammatory  or  ulcerative  process  which 
results  in  adhesions  between  the  vaginal  walls.  The  more  important  causes 
may  be  briefly  set  down  as  follows  : 

Puerperal  Infection  or  Lacerations. —  Occasionally,  as  a  result  of 
puerperal  infection,  there  may  l>e  more  or  less  severe  sloughing  of  either 


GYNATRESIA  AND  RETENTION  OF  THE  MENSTRUAL  DISCHARGE      185 


the  cervical  or  vaginal  mucosa,  with  cicatricial  closure  of  the  canal  as  a 
result.  Less  frequently  extensive  lacerations  may  produce  the  same  effect. 
Infectious  Diseases. —  The  acute  exanthemata  may  rarely  cause  severe 
ulcerative  inflammation  of  the  vagina,  with  resulting  gynatresia.  Scarlet 
fever  and  diphtheria  are  perhaps  of  greatest  importance  in  this  respect.  In 
addition  to  the  general  infections,  intense  local  infections  with  the  gonococ- 
cus  may  at  times  be  followed  by  gynatresia. 


jiMKien 


--.Obstruct  wv^Q^M^emWawe. 


Fig.  29. —  Acquired  Atresia  of  the  Vagina  or  Hymen. 

A  ,  semidiagram,  showing  the  cavities  formed  in  the  genital  tract  by  the  obstructed 
menstrual  blood.  Hematocolpos  in  the  vagina,  hematometra  in  the  body  of  the  uterus,  and 
hematosalpinx  in  the  tubes  (Graves). 

Trauma. —  Various  forms  of  external  injury  may  be  followed  by  closure 
of  the  vaginal  canal.  Such  injuries  as  those  produced  in  children  by  falls 
astride  a  chair  are  especially  important  in  this  connection.  Under  this  same 
heading  may  be  placed  the  injuries  caused  by  corrosive  substances,  such  as 
acids.  In  the  cervix  the  most  frequent  cause  of  atresia  of  this  type  is 
excessive  cauterization,  either  with  chemicals  (zinc  chlorid,  carbolic  acid, 
etc.)  or  with  the  actual  cautery.  Spalding  has  recently  reported  a  case  of 
cervical  occlusion,  with  retained  menses,  observed  in  a  woman  of  29,  as  a 
result  of  an  improperly  performed  amputation  of  the  cervix.  The  uterus 
was  distended  to  the  size  of  a  grapefruit. 

Senile  Atresia. —  Special  mention  may  be  made  of  this  cause  of  gyna- 
tresia, on  account  of  its  frequency  and  consequent  importance.  As  a  woman 
approaches  the  menopause,  even  before  menstruation  ceases,  retrogressive 


186  MENSTRUATION  AND  ITS  DISORDERS 

changes  in  the  mucosa  of  the  genital  canal  may  become  marked  (see  Chapter 
XIII).  The  thin,  pasty,  anemic  appearance  of  the  vulvar  and  vaginal 
mucosa  in  women  at  this  period  is  due  to  a  gradual  replacement  of  the 
lining  epithelium  with  connective  tissue.  This  retrogressing  mucosa  is  ex- 
ceedingly liable  to  inflammatory  processes  (senile  vulvovaginitis),  with  a 
marked  tendency  to  ulceration.  The  sequel  to  the  latter  is  often  a  pro- 
nounced contraction  and  perhaps  even  complete  closure  of  the  vagina.  The 
same  process  may  less  frequently  involve  the  cervix  or  the  body  of  the  uterus. 

When  atresia  of  this  type  occurs  in  the  woman  in  whom  menstruation  has 
not  yet  ceased,  the  result  is  of  course  retention  of  the  menstrual  discharge. 

Even  in  women  far  beyond  the  age  of  the  menopause,  however,  gynatresia 
may  be  associated  with  extensive  accumulations  of  blood  in  the  generative 
canal.  A  good  illustration  of  this  fact  is  furnished  by  the  recent  case  of 
Gellhorn.  His  patient  was  a  woman  of  74,  who  had  passed  the  menopause 
35  years  previously.  An  attack  of  severe  pain  led  to  the  discovery  of  a 
"  large  fluctuating  tumor  which  filled  the  entire  pelvis  and  extended  upward 
almost  to  the  umbilicus."  Examination  showed  that  there  was  senile  atresia 
of  the  vagina,  the  canal  being  closed.  At  operation  the  tumor  was  found  to 
consist  of  a  large  hematocolpos,  hematometra,  and  double  hematosalpinx. 
Panhysterectomy  was  followed  by  death  from  embolism  on  the  fifteenth  day. 
Examination  of  the  specimen  showed  that  the  source  of  the  blood  in  this  case 
was  an  adenocarcinoma  of  the  fundus.  A  somewhat  similar  case  has  been 
reported  by  Sondheimer.  Other  instances  of  postclimacteric  hematometra 
are  recorded  by  Chrobak,  Savidge,  Stein,  Verdier  and  others. 

Mechanical  Occlusion  from  Within  or  Without  the  Genital 
Canal. —  Perhaps  the  most  familiar  type  of  mechanical  occlusion  of  the 
genital  canal  is  that  occasionally  produced  by  carcinoma  of  the  cervix.  It  is 
not  rare  for  cervical  cancer,  especially  adenocarcinoma,  to  block  the  canal 
completely,  so  that  the  menstrual  blood  is  backed  up  in  the  uterus  (hemato- 
metra). As  a  rule,  however,  secondary  infection  soon  takes  place,  pyometra 
being  the  result.  Other  tumors,  such  as  polypi,  may  occasionally  cause 
similar  occlusion  of  the  genital  canal. 

Another  relatively  frequent  form  of  genital  occlusion,  with  accumulation 
of  blood,  is  found  in  the  tube  as  a  result  of  torsion,  usually  in  connection  with 
torsion  of  the  pedicle  of  an  ovarian  tumor.  It  must  be  borne  in  mind, 
however,  that  the  bloody  content  of  the  tube  in  these  cases  is  not  retained 
menstrual  blood,  but  a  hemorrhagic  exudate  due  to  the  disturbance  of  the 
tubal  circulation. 

A  rather  interesting  case  has  been  reported  by  Child,  in  which  he  attributes 
"  regurgitant  menstruation  through  the  fallopian  tubes  "  to  an  "  antipreg- 
nancy  button  "  which  had  been  worn  by  the  patient  for  three  months  without 
removal.  In  addition  to  the  difficulty  of  excluding  tubal  pregnancy  in  such 
a  case,  however,  there  is  also  the  possibility  of  the  bloody  exudate  in  the 
tubes  having  been  due  to  tubal  infection,  perhaps  consequent  to  the  presence 
of  the  foreign  body. 


GYNATRESIA  AND  RETENTION  OF  THE  MENSTRUAL  DISCHARGE      187 

Symptoms  of  Gynatresia. —  Until  the  inauguration  of  the  menstrual 
function,  gynatresia  produces  no  symptoms,  and  hence  is  commonly  unrecog- 
nized. Often  attention  is  directed  to  the  condition  by  the  failure  of  the 
menses  to  appear  at  the  usual  age.  As  a  rule,  however,  there  is  a  history 
of  menstrual  molimina  in  such  cases.  Even  though  there  is  no  external 
appearance  of  the  menses,  the  girl  suffers  more  or  less  discomfort  at  the 
menstrual  periods  —  a  sensation  of  weight  and  heaviness  in  the  pelvis, 
backache,  headache,  etc.  Sooner  or  later,  there  is  actual  pain  at  the  monthly 
periods,  usually  of  a  more  or  less  colicky  character. 

As  the  condition  advances  to  the  development  of  hematocolpos,  hemato- 
metra,  and  perhaps  hematosalpinx,  a  tumor  is  observed  in  the  lower  abdo- 
men. Even  before  this,  in  the  ordinary  case  of  imperforate  hymen,  there 
is  a  bulging  at  the  site  of  the  occluding  membrane,  which  is  pushed  outward 
by  the  mass  of  accumulated  blood  behind  it.  In  exaggerated  cases  pain  and 
tenderness  may  be  present  continuously,  due  to  the  pressure  of  the  tumor, 
and  to  the  pelvic  peritonitis  which  is  often  associated  with  it. 

Chemical  Composition  of  Retained  Menstrual  Discharge. —  An 
analysis  has  been  made  by  Bell  of  the  retained. fluid  found  in  ten  cases  of 
hematocolpos.  JMucin  formed  a  large  fraction,  about  one  third  of  the  fluid. 
Lactic  acid  was  present  in  the  absence  of  bacteria,  and  hence  could  not  be 
due  to  the  vaginal  bacillus  of  Doderlein.  Fibrin  ferment  and  fibrinogen 
were  absent,  according  to  Bell,  explaining  the  non-coagulability  of  the 
menstrual  blood  (Chapter  VIII).  The  calcium  content  Bell  found  to  be 
very  great,  \vhile  urea  was  absent. 

Cause  of  Hematosalpinx  in  Cases  of  Gynatresia. —  It  is  by  no  means 
as  easy  to  explain  the  production  of  hematosalpinx  as  of  hematometra  or 
hematocolpos.  The  two  latter  conditions  are  obviously  due  to  mere  reten- 
tion of  menstrual  blood.  It  is  true  that  there  are  many  who  would  explain 
hematosalpinx  in  the  same  manner,  although  this  explanation  takes  for 
granted  a  doubtful  point,  viz.,  that  the  menstrual  blood  regurgitates  into 
the  tube,  forcing  its  way  through  the  normally  tiny  uterine  orifice  of  the 
tube.  Others  believe  that,  while  the  blood  in  the  hematosalpinx  is  mentrual 
blood,  its  source  is  not  the  uterus,  but  rather  the  tubal  mucosa  itself.  As 
stated  elsewhere  (Chapter  III),  however,  the  best  evidence  is  opposed  to 
the  theory  of  tubal  participation  in  menstruation. 

This  difficulty  is  evaded  by  those  who,  like  Pozzi,  believe  that  in  these 
cases  the  tubes  assume  a  vicarious  menstrual  function,  and  that  the  bloody 
contents  of  a  hematosalpinx  represent  a  vicarious  menstrual  discharge. 
Another  theory  which  may  be  mentioned  is  that  the  blood  arises  from  the 
tubal  wall  either  as  a  result  of  a  circulatory  disturbance  or  of  an  inflamrha- 
tory  reaction.  The  view  of  Mason  and  Bandl,  that  the  blood  has  its  source 
from  ruptured  graafian  follicles,  is  too  far  fetched  to  merit  serious  consid- 
eration. 

Diagnosis  of  Gynatresia. —  In  the  great  majority  of  cases  the  diag- 
nosis is  simple.     The  failure  of  menstruation  to  appear  at  the  usual  age. 


188  MENSTRUATION  AND  ITS  DISORDERS 

when  combined  with  the  occurrence  of  definite  menstrual  molimina,  should 
make  one  suspicious.  The  presence  of  an  imperforate  hymen  can  usually 
be  determined  by  inspection.  When  the  obstruction  is  higher  up,  the  diag- 
nosis may  be  more  difficult.  When  taken  together  with  the  history,  careful 
physical  examination  will  usually  determine  the  condition  which  exists.  In 
cases  of  absence  of  the  vagina  or  of  vaginal  atresia,  bimanual  examination, 
with  one  finger  in  the  rectum,  is  often  of  great  service. 

Prognosis. —  Gynatresia,  with  retention  of  menstrual  fluid,  must  be 
looked  upon  as  a  serious  condition.  In  former  years  the  mortality  was 
quite  appalling.  Fuld,  in  1888,  reported  a  mortality  of  74  per  cent  in  65 
cases.  Of  the  48  fatal  cases,  9  died  without  operation  having  been  per- 
formed. Such  a  mortality  rate  would  not,  of  course,  apply  to  the  present 
day,  but  the  condition  is  still  fraught  with  no  little  danger.  The  principal 
complications  to  be  feared  are  rupture  of  the  sac,  with  perhaps  fatal  hemor- 
rhage or  shock,  and  peritonitis.  The  tubal  fluid,  for  some  as  yet  unex- 
plained reason,  is  said  by  most  authors  to  possess  a  disproportionate  degree 
of  infectiousness,  and  its  expulsion  into  the  abdominal  cavity  is  therefore 
associated  with  great  danger.  Cases  of  spontaneous  cure  by  rupture  into 
the  bladder  or  rectum,  or  through  the  septum  of  a  double  uterus,  have  been 
observed. 

Treatment. —  The  treatment  of  the  various  forms  of  gynatresia 
which  produce  menstrual  retention  is  surgical.  The  operation  indicated 
depends  upon  various  factors,  but  chiefly  upon  the  location  of  the  obstruc- 
tion. The  most  common  type,  the  imperforate  hymen,  is  best  treated  by 
excision  of  the  obstructing  hymen  under  rigidly  aseptic  precautions.  The 
technic  of  this,  as  well  as  of  the  other  operative  procedures  indicated  in  other 
types  of  atresia,  is  described  in  the  various  text  books  of  operative 
gynecology. 

XIX 

LITERATURE 

Andrews.     Two  Cases  of  Retention  of  Menses  in  which  the  Peritoneal  Cavity 
Contained  Free  Blood.     J.  Obst.  &  Gyn.,  Brit.  Emp.,  191 1,  19,  521. 

A  Clinical  Lecture  on  Retention  of  Menses.     Clin.  J.  London,   1909, 

35,61. 

Bell.     Case  of  Retained  Menses  with  Perforation  of  the  Bladder.     Tr.  Edinb. 
Obst.  Soc,  1894,  19,  181. 

The  Nature  of  Hematocolpos  Fluid,  and  the  Character  of  the  Obstruct- 
ing Membrane.     Lancet,  191 1,  i,  1269. 

Brothers.     Ueber  Atresia  Vaginae  mit   Flamatometra,   Hamatosalpinx  und 

Hamatovarium,  etc.     Gyn.  Rundsch.,  1908,  2,  837. 
Child.     Regurgitant  Menstruation  through  Fallopian  Tube.     Amer.  J.  Obst., 

1916,  74,  484. 
Chrobak.     Beitrag  zur  Therapie  des  Carcinoma  Uteri  mit  einer  Anmerkung 

uber  Hydrometra.    Wien,  Med,  Wchnsch.,  1887,  37,  1460. 


GYNATRESIA  AND  RETENTION  OF  THE  MENSTRUAL  DISCHARGE      189 

CowEN.     A  Case  of  Retained  Menses.     Practitioner,  1911,  86,  724. 
CuLLiNGWORTH.     On  Retention  of  Menstrual  Fluid,  in  Cases  of  Bicornuate 

Uterus,  from  Bilateral  Atresia  of  Uterus  or  Vagina.     Am.  J.  Obstet., 

1893,  27,  817. 
DoRAN  AND  LocKYER.     Two  Cases  of  Uterus  Septus  Unicollis,  etc.     Jour. 

Obst.  and  Gyn.,  Brit.  Emp.,  1905,  7,  167. 
FoRDVCE.     Complete  Absence  of  Vagina;    Regurgitation  of  Menstrual  Blood 

through  Fallopian  Tube  into  Peritoneal  Cavity;   with  Notes  of  Unusual 

Case.     Tr.  Edinb.  Obst.  Soc,  1911-12,  37,  224. 
Gellhorn.     Haematocolpos,  Haematometra  and  Haematosalpinx  in  Woman 

of  Seventy-four.     Surg.  Gyn.  and  Obst.,  1917,  24,  37. 
Hall.     Diagnosis  of  Menstrual  Reflux  through  Tubes.     Jour.  A.  M.  A.,  1916, 

dj,  1040. 
Hartill.     a  Case  of  Retained  Menses  Relieved  by  Operation.     Brit.  M.  J., 

1910,  I,  71. 
Kermauner.     Zur  Atiologie  der  Gynatresien.     Beitr.  f.  Geb.  u.  Gyn.,   191 3, 

18,  187. 
Kussmaul.     Quoted  by  Cullingworth. 
Landau  und  Rheinstein.     Ueber  das  Verhalten  der  Schleimhaute  in  Ver- 

schlossenen  und  Missbildeten  Genitalien  und  iiber  die  Tubenmenstrua- 

tion.     Arch.  f.  Gyn.,  1892,  42,  273. 
Landsberg.     Ueber   Hamatosalpinx   und   Tubenmenstruation.     Inaug.    Diss., 

Breslau,  1896. 
Lewers.     Double  Uterus  (Atresia  of  One-half)   with  Dysmenorrhea.     Proc. 

Roy.  Soc.  Med.,  1909-10,  3,  Obst.  and  Gyn.  Sect,  241. 

On    Congenital   Haematocolpos,    Haematometra,   and    Haematosalpinx, 

with  Notes  of  Case  Requiring  Laparotomy.     Practitioner,  1910,  85,  137. 

Maclean.     Dysmenorrhea;  Hematometra  of  One  Horn  of  Uterus  Bicornis. 

J.  Obst.  and  Gyn.  Brit.  Emp.,  191 1,  20,  18. 
Mayne.     Notes  on  Two  Cases  of  Imperforate  Hymen  in  Sisters.     Lancet, 

1910,  I,  1619. 
MoNDY.     Retained  Menses  in  a  Girl  of  Fourteen-and-a-half  Years  —  Sponta- 
neous Relief.     Edinb.  M.  J.,  1910,  4,  541. 
Nagel.     Zur  Lehre  von  der  Atresia  der  Weiblichen  Genitalien.     Verhandl.  d. 

Deutsch.  Gesellsch.  f.  Geb.  u.  Gyn.,  Berlin,  1896,  34,  381. 
Novak.     Congenital  Absence  of  Uterus  and  Vagina,  with  Report  of  .Six  Cases. 

Surg.,  Gyn.  and  Obst,  1917,  25,  532. 
RuGE.     Ueber  Gynatresien  in  der  Graviditat.     Arch.  f.  Gyn.,  1914,  102,  264. 
Savidge.     Hematometra  in  a  Woman  of  Sixty-five.     Amer.  J.  Obst.,  1910,  60, 

108. 
Sieber.     Ein   Fall  von  Hematometra  in   Nebenhorn  eines  Uterus   Bicornis. 

Deutsch.  Med.  Wchnsch.,  191 1,  37,  1657. 
Spalding.     Cervical  Occlusion  with  Retained  Menses.     Intern.  Clin.,  1918,  4, 

245- 
Stein.     Hematometra  in  an  Aged  Woman.     Amer.  J.  Obst.,  1910,  60,  107. 

Ein  Seltener  Fall  von  Hamatometra.     Zentralb.  f.  Gynak.,  1910,  34,  97. 

Thoma.     Zur  Atiologie  der  Gynatresie.     Monats.  f.  Geb.  u.  Gyn.,  1913,  38,  i. 
Verdier.     Quoted  by  Gellhorn. 

Veit.     Ueber  Haematosalpinx  bei  Gynatresie.     Berl.  Klin.  Wchnsch.,   1896, 

33,  343- 


CHAPTER  XX 
DYSMENORRHEA 

General  Considerations. —  The  term  dysmenorrhea,  literally  trans- 
lated, means  difficult  menstruation,  and  is  apphed  to  the  condition  in  which 
there  is  pain  at  the  time  of  the  menstrual  flow.  In  the  normal  healthy 
woman,  the  occurrence  of  the  menses  should  be  accompanied  with  little  or 
no  pain.  In  most  women  the  menstrual  periods  are  associated  with  certain 
subjective  symptoms,  the  so-called  menstrual  molimina.  At  these  times 
there  is  often  a  sensation  of  heaviness  in  the  pelvis,  general  lassitude,  some- 
times headache,  and  often  a  condition  of  nervousness  and  increased  irrita- 
bility. Under  ordinary  conditions,  however,  these  symptoms  are  not  suffi- 
cient to  inconvenience  the  woman  to  any  extent.  When,  on  the  other  hand, 
the  occurrence  of  menstruation  is  characterized  by  more  or  less  severe  pain, 
the  condition  is  spoken  of  as  dysmenorrhea.  There  has  been  much  discus- 
sion regarding"  the  proper  application  of  this  term.  There  is  no  sharp 
dividing  line  between  the  moderate  discomfort  which  so  often  accompanies 
normal  menstruation,  and  the  definite  pain  which  constitutes  dysmenor- 
rhea. The  individual  factor  obviously  plays  a  most  important  role  in 
determining  the  degree  of  such  a  purely  subjective  symptom  as  pain.  As 
already  stated,  the  word  dysmenorrhea  implies  difficult  or  obstructed  men- 
struation, and  it  is  therefore  looked  upon  by  some  as  a  misnomer,  inasmuch 
as  menstruation  is  often  accompanied  by  great  pain  in  the  absence  of  any 
actual  obstruction.  For  this  reason  the  term  "  menorrhalgia"  has  been 
suggested  by  Massey  as  a  substitute. 

The  most  typical  cases  of  dysmenorrhea  are  seen  in  the  entire  absence  of 
any  discoverable  pathological  lesion  in  the  pelvis.  There  is  no  difference 
of  opinion  of  the  applicability  of  the  term  dysmenorrhea  to  such  cases.  On 
the  other  hand,  pain  at  the  time  of  the  menstrual  periods  is  often  seen  in 
women  suffering  with  inflammatory  or  other  disease  in  the  pelvis,  the  extra 
congestion  of  the  menstrual  period  appearing  to  provoke  or  accentuate  the 
pain.  The  history  of  such  cases  often  shows  that  there  was  no  menstrual 
pain  whatsoever  before  the  occurrence  of  the  pelvic  lesion.  There  are  some 
authors,  notably  Herman,  who  insist  that  the  term  dysmenorrhea  cannot  be 
properly  applied  to  such  cases,  and  that  it  should  refer  only  to  those  cases  in 
which  there  is  no  discoverable  pelvic  lesion,  i.  e.,  to  those  in  which  the  cause 
appears  to  be  intrinsically  uterine.  From  the  clinical  point  of  view,  at  least, 
nothing  is  gained  by  making  such  a  distinction.  It  seems  more  logical  to 
apply  the  term  dysmenorrhea  to  all  instances  of  pelvic  pain  associated  with 

190 


DYSMENORRHEA  191 

the  occurrence  of  menstruation,  and  then  to  subdivide  the  cases  into  two 
principal  groups,  the  primary  and  the  secondary. 

Types  of  Dysmenorrhea. —  Primary  dysmenorrhea  may  be  defined  as 
that  form  in  which  menstrual  pain  occurs  in  the  entire  absence  of  gross 
pathological  lesions  in  the  pelvis.  Secondary  dysmenorrhea,  on  the  other 
hand,  refers  to  those  cases  in  which  the  pain  at  menstruation  is  associated 
with  and  apparently  due  to  definite  pelvic  disease  of  one  form  or  another. 
This  division  is  of  course  based  upon  etiological  considerations. 

From  a  clinical  viewpoint  it  is  convenient  to  adopt  Kelly's  division  of 
cases  of  dysmenorrhea  into  two  types,  which  m^ay  be  called  the  spasmodic 
and  the  congestive.  In  the  former  the  "  pain  begins  just  before  or  exactly 
with  the  appearance  of  menstruation.  It  is  sharp,  well  defined,  and  cramp 
like  in  character,  coming  on  in  paroxysms  which  last  a  minute  or  two  and 
recur  at  short  intervals."  The  suffering  is  not  only  more  severe,  but  also 
of  a  different  character  from  that  accompanying  normal  menstruation. 

In  the  congestive  type,  on  the  other  hand,  the  pain  appears  to  be  an 
increase  of  the  usual  discomfort  of  the  menstrual  periods.  "  The  pain 
begins  from  one  to  two  days  to  a  week  before  the  appearance  of  the  flow. 
It  is  of  a  dull,  dragging  character,  extending  all  through  the  back  and  down 
the  thigh,  and  is  often  accompanied  by  severe  headache,  occasionally  asso- 
ciated with  nausea,  extreme  lassitude,  and  nervous  excitability.  In  some 
cases  the  symptoms  are  greatly  relieved  by  the  establishment  of  menstrua- 
tion ;   in  others,  they  continue  throughout  its  duration." 

The  spasmodic  form  is  especially  characteristic  of  primary  dysmenorrhea, 
and  the  congestive  form  is  more  common  with  the  secondary  type,  although 
exceptions  to  this  rule  are  not  infrequent.  Occasionally,  both  types  of  pain 
are  present  in  the  same  patient. 

Frequency  of  Dysmenorrhea. —  Little  importance  can  be  attached  to 
figures  indicating  the  incidence  of  dysmenorrhea,  inasmuch  as,  with  regard 
to  the  secondary  form  at  least,  the  frequency  is  largely  dependent  on  the 
frequency  of  pelvic  disease.  In  Chapter  VIII  are  given  the  statistics  of 
various  authors  of  the  frequency  of  pain  at  the  time  of  menstruation.  The 
fact  that  these  statistics  can  take  no  account  of  the  "  personal  factor  "  in 
dysmenorrhea,  and,  moreover,  the  fact  that  no  attempt  was  made  in  such 
studies  to  separate  primary  and  secondary  cases,  detracts  a  great  deal  from 
their  significance. 

CAUSES  OF  PRIMARY  DYSMENORRHEA 

General  Considerations. —  The  extreme  frequency  of  this  form  of 
dysmenorrhea,  together  with  the  severe  pain  and  perhaps  disability  which 
it  entails,  has  made  it  the  subject  of  much  study.  This,  however,  has  been 
almost  entirely  along  clinical  lines,  and  it  cannot  be  said  that  much  of  real 
scientific  worth  has  been  contributed.  The  problem  of  the  cause  of  primary 
dysmenorrhea  is  still  unsolved,  and  it  remains  one  of  the  big  questions  still 


192  MENSTRUATION  AND  ITS  DISORDERS 

confronting  g}'necologists.  Many  theories  have  been  suggested  to  explain 
the  mechanism  by  which  the  pain  is  produced  in  these  cases.  In  many 
instances  more  than  one  factor  is,  no  doubt,  concerned.  According  to  the 
principal  views  reg'arding  the  causation  of  primary  dysmenorrhea,  one  or 
more  of  the  following  factors  may  be  concerned  :  ( i )  Mechanical  obstruction 
of  the  uterine  canal ;  (2)  Hypoplasia  of  the  generative  organs;  (3)  Neuroses 
of  one  form  or  another;  and  (4)  Constitutional  diseases. 

Mechanical  Obstruction  of  the  Uterine  Canal. —  It  w^as  at  one  time 
believed  that  dysmenorrhea  is  always  due  to  some  mechanical  obstruction 
to  the  free  exit  of  the  menstrual  blood.  This  belief  dates  from  the  time  of 
Mackintosh,  of  England,  who,  in  1832,  reported  twenty-seven  cases  in 
which  he  had  done  dilatation  of  the  uterine  canal  for  the  relief  of  the 
obstruction  to  which  he  attributed  the  dysmenorrhea.  Twenty-four  of  these 
he  reported  to  have  been  cured.  This  doctrine  was  greatly  strengthened  by 
the  endorsement  which  it  received  from  two  of  the  greatest  gynecologists 
of  the  time  —  Marion  Sims  and  Sir  James  Y.  Simpson.  It  was  Sims  who, 
in  his  classical  paper  entitled  "  Nulla  Dysmenorrhea  nisi  Obstructiva," 
asserted  that  "  there  can  be  no  dysmenorrhea,  properly  speaking,  if  the  canal 
of  the  neck  of  the  uterus  be  straight  and  wide  enough  to  permit  a  free 
passage  of  the  menstrual  blood."  In  the  same  way,  Robert  Barnes,  of 
London,  stated  "mechanical  obstruction  of  the  secretions  is  the  most  im- 
portant factor  in  dysmenorrhea.  The  essential  condition  of  dysmenorrhea 
is  a  retention  of  the  menstrual  secretion." 

Even  at  the  present  time  many  text  books  and  authors  lay  great  stress 
upon  the  importance  of  mechanical  obstruction  in  the  production  of  dysmen- 
orrhea. On  the  whole,  however,  this  theory  has  been  considerably  shaken 
by  numerous  observations  showing,  on  the  one  hand,  that  dysmenorrhea 
may  occur  in  the  entire  absence  of  any  mechanical  obstruction,  while,  on 
the  other  hand,  it  may  be  absent  where  a  greater  or  less  degree  of  obstruc- 
tion is  present.  Menstrual  pain,  for  instance,  is  frequently  present  when 
the  uterine  canal  is  widely  patulous.  It  has  been  shown  that  in  cases  of 
dysmenorrhea,  supposedly  due  to  cervical  obstruction,  a  uterine  sound  may 
easily  be  passed  through  the  cervical  canal  during  the  menstrual  period, 
showing  that  there  can  be  no  very  great  obstacle  to  the  free  outflow  of  blood 
from  the  uterus. 

The  average  amount  of  blood  given  off  at  each  menstrual  period  is  two  to 
eight  ounces,  or,  assuming  that  the  menstrual  flow  lasts  three  or  four  days, 
not  more  than  two  ounces  each  day.  This  is  equivalent  to  saying  that 
about  forty  drops  come  through  the  cervical  canal  each  hour,  or  two  thirds 
of  a  drop  each  minute.  It  would  seem  difficult  to  conceive  that  the  cervix 
in  these  cases  of  dysmenorrhea  could  be  obstructed  to  such  a  degree  as  not 
to  allow  the  passage  of  this  small  amount  of  blood.  Furthermore,  it  is  not 
uncommon  to  find  severe  dysmenorrhea  in  cases  in  which  an  excessively  large 
amount  of  menstrual  blood  is  passed. 

Perhaps  the  principal  argument  in  favor  of  the  view  that  mechanical 


DYSMENORRHEA  193 

obstruction  may,  at  least  in  some  cases,  be  responsible  for  dysmenorrhea  is 
the  fact  that  a  certain  number  of  cases  of  the  primary  form  are  reheved  by 
dilatation  of  the  uterus.  On  the  other  hand,  an  even  larger  number  are  not 
relieved  at  all,  or  are  improved  only  temporarily,  IMoreover,  when  the 
genital  canal  is  actually  obstructed,  as  in  gynatresia,  the  resulting  pain  is 
rarely  of  the  type  seen  clinically  in  cases  of  spasmodic  dysmenorrhea. 
Certainly  it  is  rarely  so  severe. 

Relation  of  Anteflexion  to  Dysmenorrhea. —  In  the  majority  of 
cases  of  primary  dysmenorrhea,  the  uterus  is  anteflexed,  and  it  is  the 
anteflexion  which  is  commonly  believed  to  cause  the  obstruction 
or  "  kink "  in  the  uterine  canal.  The  association  of  anteflexion  with 
dysmenorrhea  has  been  studied  by  many  authors.  The  conclusions  of 
Herman  on  the  subject  represent  the  opinion  of  the  majority  of  the  leading 
authorities.    They  are  as  follows  : 

*'  First :  There  is  no  anatomical  evidence  that  anteflexion  causes  any 
appreciable  hindrance  to  the  escape  of  menstrual  fluid. 

"  Second :  There  is  reason  to  think  that  w^ell  marked  anteflexion  is  pres- 
ent in  nearly  one  half  of  all  women  who  have  not  borne  children. 

"  Third :  Therefore,  it  is  to  be  expected  that  anteflexion  and  dysmenor- 
rhea would  frequently  coincide. 

"  Fourth :  Dysmenorrhea  is  practically  as  common  when  the  uterus  is 
anteflexed  as  when  it  is  not. 

"  Fifth :  When  dysmenorrhea  and  flexion  go  together,  the  severity  of 
the  pain  bears  no  relation  to  the  degree  of  the  bending. 

"  Sixth :  Dysmenorrhea  associated  with  anteflexion  is  frequently  cured 
without  straightening  the  uterus. 

"  Seventh :  There  is  no  evidence  that  straightening  the  uterus  invariably 
or  frequently  removes  dysmenorrhea  which  is  associated  with  anteflexion, 
and  in  which  other  methods  of  cure  have  been  ineffectual. 

"  Eig'hth  :  These  facts  tend  to  show  that  the  relation  between  anteflexion 
and  painful  menstruation  is  not  that  of  cause  and  effect,  but  that  of 
coincidence." 

Hypoplasia  of  Reproductive  Organs. —  Closely  related  tO'  so-called 
obstructive  dysmenorrhea  is  that  form  which  is  so  frequently  associated 
with  defective  development  of  the  pelvic  organs.  Even  in  women  who  are 
otherwise  robust  and  well  developed,  it  is  not  rare  to  find  the  uterus  small 
and  hypoplastic,  and  perhaps  distinctly  infantile  in  type.  (Fig.  30.)  The 
infantile  character  of  the  uterus  in  these  cases  is  further  shown  by  the  fact 
that  it  is  frequently  anteflexed.  It  will  be  remembered  that  the  uterus  of 
the  female  fetus  or  infant  is  often  anteflexed,  so  that  conditions  in  which 
the  uterus  remains  very  small  and  anteflexed  may  be  looked  upon  as 
representing  an  arrest  of  development. 

From  our  present  standpoint  these  cases  are  of  interest  because  they  are 
quite  characteristically  associated  with  more  or  less  severe  dysmenorrhea. 
Incidentally,  it  may  be  said  that  sterility  is  also  found  in  the  majority  of  such 


194 


MENSTRUATION  AND  ITS  DISORDERS 


cases.  These  three  manifestations  —  infantile  uterus,  dysmenorrhea,  ster- 
ihty  —  constitute  a  triad  famihar  to  every  practicing  physician  on  account 
of  the  frequency  of  its  occurrence.  This  is  one  of  the  most  interesting  forms 
of  dysmenorrhea  with  which  we  have  to  deal,  and  at  the  same  time  the 
most  intractable,  on  account  of  the  fact  that  so  little  is  known  concerning  the 
exact  mechanism  of  its  production. 

Various  theories  liave  been  suggested  to  explain  the  pain  observed  in 
these  cases.  There  are  some  who  believe  that  the  dysmenorrhea  seen  in 
these  cases  is  to  be  looked  upon  as  obstructive  in  type ;  in  other  words,  that 
it  is  due  to  the  cervical  stenosis,  or  the  kink  in  the  cervical  canal  produced 
by  the  sharp  anteflexion.  Others,  again,  suggest  that  it  is  due  to  the  fact 
that  at  the  time  of  menstruation  the  endometrium  undergoes  marked  swell- 


FiG.  30. —  An  Ulongate  Infantile  Ovary  With  Puerile  Type  of  Uterine  Body  (Kelly). 

ing  and  congestion,  the  small  uterine  cavity  being  unable  to  accommodate 
this  hypertrophied  endometrium.  Still  others  believe  that  it  is  the  dilatation 
of  the  blood  vessels  in  the  muscularis  rather  than  the  swelling  of  the  mucous 
membrane  which  is  responsible  for  the  pain. 

The  theory  of  an  obstructive  origin  of  the  pain,  as  we  have  already  seen, 
is  no  longer  tenable.  The  investigations  of  Schultz  tend  to  support  the 
view  that  dysmenorrhea  of  the  type  now  under  discussion  is  due  to  what 
may  be  called  the  vascular  tension  resulting  from  deficient  calibre  of  the 
uterine  vessels. 

This  investigator  states  that  up  to  the  age  of  puberty  the  uterus  has  the 
form  of  the  "  infantile  "  uterus,  as  we  find  it  clinically  in  association  with 
spasmodic  dysmenorrhea.  Under  normal  conditions  the  uterus  at  puberty 
enters  upon  a  process  of  development  continuing  up  to  about  the  twentieth 


DYSMENORRHEA  195 

year,  when  the  full  maturity  of  the  organ  is  attained.  The  mature  uterus 
contains  a  preponderance  of  muscle  over  connective  tissue,  unlike  the  imma- 
ture organ,  in  which  the  proportion  between  connective  tissue  and  muscle  is 
that  of  two  to  one.  In  cases  of  "  nifantile  uterus,"  associated  with  spasmodic 
dysmenorrhea,  there  has  been  a  retardation  of  development  in  the  organ, 
so  that,  like  the  undeveloped  uterus,  it  contains  a  preponderance  of  connec- 
tive tissue. 

The  normal  hyperemia  of  menstruation  causes  an  engorgement  of  the 
uterine  vessels,  producing  what  Schultz  describes  as  a  capsular  distention 
of  the  connective  tissue  layers  in  which  are  contained  the  blood  vessels. 
Owing  to  the  deficiency  of  muscle  tissue  in  the  uterine  wall,  there  is  a  stag- 
nation of  the  blood  in  the  uterine  veins.  This  venous  stasis  gives  rise  to 
pressure  stimulation  of  the  uterine  nerves,  and  thereby  to  the  characteristic 
spasmodic  labor-like  contractions  which  are  responsible  for  the  pain. 

Some  recent  studies  which  I  have  made,  on  the  menstrual  reaction  of  the 
endometrium  in  various  types  of  pelvic  disease,  have  seemed  to  me  to  throw 
some  light  on  this  question.  In  a  clinical  and  anatomical  investigation  of  a 
large  series  of  cases  from  the  gynecological  department  of  the  Johns  Hopkins 
Hospital,  I  was  able  to  demonstrate  that,  generally  speaking,  the  degree  of 
premenstrual  hypertrophy  in  the  endometrium  is  proportionate  to  the  clin- 
ical severity  of  the  menstrual  bleeding,  with  the  exception  of  one  important 
group,  the  cases  of  congenital  anteflexion  of  the  uterus. 

In  these,  even  though  menstruation  is  usually  rather  scanty,  the  menstrual 
reaction  is  often  noted  unusually  early  in  the  menstrual  cycle,  and  may 
become  very  marked.  This  is  rather  surprising,  since  we  are  accustomed  to 
look  upon  these  cases  as  representing  a  greater  or  less  degree  of  arrested 
development.  In  some  of  my  cases  the  uterus  was  distinctly  infantile  in 
type.  Menstruation  was  much  more  frequently  scanty  or  moderate  than 
profuse.  Dysmenorrhea  was  observed  in  practically  all  the  cases,  and  in 
those  of  the  patients  who  were  married  sterility  was  almost  invariable. 

Since  the  histological  reaction  of  the  hypoplastic  uterus  to  menstruation 
is  certainly  not  any  less  than  that  of  the  normal  organ,  the  question  arises 
as  to  why  menstruation  is  usually  scanty  in  the  hypoplastic  cases.  If  it  be 
true,  as  the  study  of  my  series  seemed  to  indicate,  that  in  congenital  ante- 
flexion there  is  no  impairment  of  ovarian  activity,  the  idea  suggests  itself 
that  perhaps  in  these  cases  there  is  just  as  great  a  degree  of  menstrual 
hyperemia  of  the  endometrium  as  in  those  in  which  the  uterus  is  well  devel- 
oped, but  that  in  the  former  it  is  the  local  factor  which  is  defective ;  in  other 
words,  that  there  is  a  physiological  as  well  as  an  anatomical  deficiency  in  the 
uterus.  This  local  factor,  it  is  commonly  believed,  exerts  Its  effect  princi- 
pally on  the  blood  vessels,  rendering  them  permeable  to  the  passage  outward 
through  their  walls  of  the  blood  elements.  In  these  cases  menstruation  may 
be  much  less  than  the  average  because  the  blood  elements  do  not  pass  out 
from  the  blood  vessels  with  the  same  facility  as  In  the  entirely  normal 
uterus.     This  hypothesis   would   seem   to   explain   the  characteristic  pain 


196 


MENSTRUATION  AND  ITS  DISORDERS 


observed  in  cases  of  this  type,  for  an  engorged  endometrium,  unrelieved  by 
menstrual  discharge  of  blood  elements,  might  be  expected  to  act  as  a  stimu- 
lant of  uterine  contractions,  much  as  a  foreign  body  would.  This  conception 
is  given  further  plausibility  by  the  characteristic  relief  from  pain  which  is 
noted  as  soon  as  the  menstrual  flow  is  well  established.  The  problem  as  a 
whole,  howeA^er,  must  still  be  considered  unsolved. 

In  conclusion,  it  may  be  emphasized  that  dysmenorrhea  is  more  frequently 
observed  in  the  milder  grades  of  uterine  hypoplasia  than  in  those  of  marked 
degree.  In  the  extreme  cases,  uterus  rudimentarius  or  uterus  fetalis  (Fig. 
31),  amenorrhea  is  the  rule.  In  patients  with  uteri  of  the  genuinely  infan- 
tile type,  uterus  infantilis  (Fig.  32),  menstruation  is  characteristically  scanty, 
while  dysmenorrhea  may  or  may  not  be  a  symptom.  In  the  relatively  slight 
degrees  of  uterine  hypoplasia,  as  represented  by  what  I  have  called  the  uterus 

1 


Pig.  31. —  The  Fetal  Type  of  Uterine  Hypoplasia  (Uterus  Rudimentarius  or  Fetalis), 
2  AND  3,  AS  Compared  With  the  Normally  Developed  Uterus,  1. 

subpubescens  (Fig.  33),  dysmenorrhea  is  the  characteristic  symptom,  the 
amount  of  the  flow  being  either  normal,  deficient,  or  excessive.  For  a  fuller 
discussion  of  these  types  of  uterine  hypoplasia  and  their  relation  to  dysmen- 
orrhea, the  reader  is  referred  to  a  recent  paper  by  the  author  on  "  Infantilism 
and  Other  Hypoplastic  Conditions  of  the  Uterus."      (See  Bibliography.) 

Role  of  Neuroses  in  Causation  of  Dysmenorrhea. —  A  third  type  of 
primary  dysmenorrhea  which  is  not  infrequently  encountered  is  that  in 
which  the  menstrual  pain  is  of  distinctly  neurotic  origin.  It  is  not  usually 
easy  to  distinguish  these  cases  with  precision  from  those  due  to  the  causes 
which  have  already  l^een  described,  especially  since  patients  suffering  from 
dysmenorrhea  due  to  hypoplasia  are  frequently  highly  neurotic  as  well. 
The  cases  coming  under  this  group  may  be  classified  under  three  headings, 
hysterical,  neurasthenic,  and  neuralgic. 


DYSMENORRHEA 


197 


Hysterical  Dysmenorrhea. —  With  regard  to  hysterical  dysmenor- 
rhea, it  must  be  emphasized  that  this  diagnosis  should  never  be  made  in  the 
absence  of  the  well  known  earmarks  of  hysteria,  such  as  hemianopsia, 
paresthesia,  anesthesia,  etc.  Hysteria  is  looked  upon  by  neurologists  as  a 
disease  of  the  cerebral  cortex,  which  may  exhibit  local  manifestations  in 
various  organs,  including  those  of  the  pelvis,     A  well  known  teacher  is 

7 


Fig.  32. —  Types  of  Infantile  Uteri  (2,  3  and  4),  in  Comparison  With  the  Normal 

Uterus  (1). 

In  all  the  cervix  predominates  over  the  corpus.  In  3  is  shown  a  moderate  corporeal 
anteflexion,  while  4  illustrates  the  more  characteristic  cervicocorporeal  anteflexion.  In 
some  cases  the  cervix  is  normal,  in  others  long  and  conical,  with  pinhole  os.  Uteri  of 
infantile  type  may  be  of  practically  normal  size,  or  they  may  be  considerably  smaller. 


Fig.  33. —  Types  of  Subpubescent  Uteri,  Showing  Only  Slight  Differences  in  Size 

FROM  Normal  Uteri  (1). 

In  2,  3  and  4  are  shown,  respectively,  corporeal  and  cervicocorporeal  anteflexion. 

quoted  as  having  made  the  statement  that  hysteria  may  be  excluded,  if  the 
pain  is  fixed.  Nothing  could  be  more  fallacious  than  this  statement.  Every 
gynecologist  is  familiar  with  the  picture  of  the  hysterical  woman  who  com- 
plains, perhaps  bitterly,  of  pain  in  the  region  of  the  ovary,  even  when  the 
most  careful  examination  fails  to  reveal  any  pathological  lesion.  In  the 
same  way,  the  hysterical  patient  may  suffer  with  intense  dysmenorrhea 


198  MENSTRUATION  AND  ITS  DISORDERS 

occurring  with  each  period,  even  when  the  pelvic  organs  are  in  themselves 
absolutely  normal.  The  dysmenorrhea  in  these  cases  is  very  often  accom- 
panied by  hysterical  convulsions  or  other  manifestations  of  characteristically 
hysterical  nature.  These  troublesome  cases  are  most  frequently  observed  in 
young  girls.  Many  of  these  patients  are  obliged  to  take  to  bed  every  month. 
It  is  especially  just  before  and  on  the  first  day  of  the  flow,  that  the  symptoms 
are  apt  to  be  most  severe,  the  patient  often  screaming  and  tossing  about  in 
a  very  unmanageable  manner. 

Dysmenorrhea  of  Neurasthenic  Origin. —  Neurasthenic  dysmenor- 
rhea is  quite  different  in  the  manner  of  its  production  —  just  as  different  as 
is  neurasthenia  from  hysteria.  Neurologists  divide  neurasthenia  into  a 
primar}^  and  a  secondary  form.  The  primary  variety  is  the  result  of  such 
factors  as  heredity,  environment,  mode  of  life,  etc.  As  the  term  itself 
indicates,  it  is  characterized  by  a  condition  of  general  weakness  or  asthenia 
of  the  nervous  system,  with  symptoms  of  the  most  varied  character  refer- 
able to  any  part  of  the  body.  Frequently  it  is  the  pelvic  organs  that  bear 
the  brunt  of  the  neurasthenic  condition,  the  most  frequent  symptom  being 
dysmenorrhea.  In  these  cases  it  is  usually  associated  with  a  greater  or  less 
amount  of  pelvic  pain  in  the  intermenstrual  period.  The  pelvic  organs 
themselves  are  often  normal  in  these  cases,  the  dysmenorrhea  representing 
merely  a  reflection  of  the  patient's  general  condition  of  neurasthenia.  When 
the  latter  is  improved,  the  dysmenorrhea  is  also  usually  relieved. 

Many  perplexing  problems  may  arise  when  dysmenorrhea  is  seen  in  neu- 
rasthenic women  who,  at  the  same  time,  have  some  distinct  pathological 
lesion  in  the  pelvis.  The  problem  in  these  cases  is  to  determine  whether 
the  dysmenorrhea  is  directly  caused  by  the  pelvic  lesion,  which  may  perhaps 
be  slight,  or  whether  it  is  only  a  part  of  the  neurasthenia.  Furthermore,  it 
must  be  ascertained,  if  possible,  whether  the  neurasthenia  in  these  cases  is 
primary,  or  whether  it  is  secondary  to  some  underlying  condition,  either 
intra-  or  extrapelvic. 

Secondary  neurasthenia  is  the  form  which  is  brought  about  by  some 
underlying  condition,  usually  some  definite  anatomic  disease.  A  woman 
with  a  normal,  well  developed  nervous  system,  for  instance,  may,  after  long 
years  of  suffering  from  some  chronic  disease,  be  reduced  to  a  condition  in 
which  her  entire  nervous  system  is  undermined,  resulting  in  secondary 
neurasthenia.  The  same  result  may,  of  course,  be  seen  after  disease  in 
other  parts  of  the  body  as  well  as  in  the  pelvis.  In  the  dysmenorrhea  which 
is  frequently  found  when  a  condition  of  neurasthenia  has  been  superimposed 
upon  one  of  original  pelvic  disease,  both  factors  must  be  considered  in 
explaining  the  production  of  the  dysmenorrhea  or  in  attempting  its  relief. 

Even  if  the  lesion  in  the  pelvis  be  removed,  women  of  this  type  often 
suffer  with  menstrual  pain  to  the  same  degree  as  before  operation.  This 
is  due  to  the  fact,  of  course,  that  the  condition  of  neurasthenia  still  persists 
and  must  be  corrected  before  any  relief  from  the  dysmenorrhea  can  be 
expected.     In  other  words,  the  neurasthenia  in  these  cases  may  be  looked 


\ 

DYSMENORRHEA  199 

upon  as  just  as  true  a  complication  of  the  pelvic  disease  as  peritonitis  is  of 
appendicitis.  Even  after  the  ruptured  appenaix  has  been  removed  we  may 
still  have  to  contend  with  the  condition  of  peritonitis.  In  the  same  way, 
even  after  diseased  pelvic  viscera  have  been  removed,  we  may  still  have  to 
deal  with  the  superimposed  condition  of  neurasthenia. 

Neuralgic  Dysmenorrhea. —  The  third  variety  of  dysmenorrhea  of 
distinctly  nervous  origin  is  the  neuralgic  form.  In  former  years  the  diag- 
nosis of  ovarian  neuralgia  or  oophoralgia  was  a  rather  common  one. 
Patients  of  this  group  complained  of  sharp  shooting  pains  over  one  or 
both  ovaries,  occurring  at  irregular  periods,  sometimes  during  the  menstrual 
epoch,  sometimes  in  the  intermenstrual  period.  In  the  broad  sense  in  which 
we  have  used  the  word  dysmenorrhea,  cases  of  this  kind  might  perhaps  be 
spoken  of  as  neuralgic  dysmenorrhea.  The  neuralgic  pains  in  these  cases 
appear  to  be  analogous  with  those  so  frequently  seen  in  the  supra-orbital  or 
intercostal  nerves.  Neurologists,  however,  are  still  in  the  dark  in  regard  to 
the  true  nature  of  neuralgia,  and,  especially  as  applied  to  the  pelvic  organs, 
this  term  should  be  used  only  with  the  greatest  caution,  if  at  all. 

CAUSES  OF  SECONDARY  DYSMENORRHEA 

General  Considerations. —  This  form  of  dysmenorrhea  may  be  the 
result  of  almost  any  of  the  numerous  forms  of  local  disease  of  the  reproduc- 
tive organs.  It  is  scarcely  necessary  to  say  that  in  the  individual  case  it  is  not 
always  easy  to  distinguish  between  primary  and  secondary  dysmenorrhea, 
inasmuch  as  the  mere  presence  of  a  pelvic  lesion  is  not  conclusive  evidence 
that  it  is  the  cause  of  dysmenorrhea,  if  the  latter  exists.  The  definition  of 
secondary  dysmenorrhea  indicates  that  constitutional  diseases  cannot  be 
looked  upon  as  direct  causes.  Undoubtedly,  however,  they  are  in  many 
instances  contributory  or  predisposing  factors  of  great  importance,  espe- 
cially in  their  influence  upon  the  severity  of  the  menstrual  pain. 

Constitutional  Disease  as  a  Predisposing  Factor. —  Speaking  gen- 
erally, any  condition  which  brings  about  a  deterioration  of  the  general  health 
and  a  lowering  of  body  resistance  may  be  associated  with  the  occurrence  of 
dysmenorrhea.  Aside  from  actual  disease,  the  poor  vitality  so  often  due  to 
bad  hygienic  surroundings,  physical  or  mental  overwork,  lack  of  proper  sleep, 
and  other  such  factors  frequently  "  lowers  the  threshold  "  to  pain  stimuli. 
The  slight  pelvic  discomfort  commonly  observed  with  normal  menstruation 
may  thus  be  magnified  to  an  actual  pain  of  greater  or  less  severity. 

Chlorosis  and  Other  Forms  of  Anemia. —  Of  the  constitutional 
diseases  which  may  cause  dysmenorrhea,  chlorosis  and  other  forms  of 
anemia  are  worthy  of  special  mention.  According  to  Virchow,  hypoplasia 
of  the  uterus  is  one  of  the  anatomic  characteristics  of  chlorosis,  and  this 
fact  may  explain  the  frequent  occurrence  of  dysmenorrhea  in  thoses  cases 
of  this  disease  in  which  menstruation  does  not  disappear  entirely.  The 
general  debility  characteristic  of  the  disease,  however,  is  a  contributing 


200  MENSTRUATION  AND  ITS  DISORDERS 

factor  of  much  importance  in  the  production  of  the  menstrual  pain  in  these 
cases.    The  same  thing  is  true  of  other  forms  of  anemia. 

Tuberculosis. —  Of  especial  interest  is  the  dysmenorrhea  which  is  so 
frequently  observed  in  cases  of  tuberculosis,  even  in  an  incipient  stage. 
AMiile  this  is  in  part  explainable  by  the  anemia  and  lowered  vitality  which 
often  mark  the  course  of  this  disease,  it  is  oi  interest  to  note  that  some 
authors  would  explain  the  dysmenorrhea  as  more  directly  the  result  of 
the  tuberculous  disease. 

f  Eisenstein  and  Hollos  record  that  one  hundred  and  eighteen  women  with 
menstrual  disturbances  gave  a  positive  reaction  to  tuberculin,  although  there 
was  nothing  else  to  suggest  the  existence  of  tuberculosis.  In  fifty-three 
such  patients  in  whom  no  other  cause  could  be  found  for  the  dysmenorrhea, 
and  who  were  subjected  to  a  course  of  tuberculin  treatment,  forty  were 
definitely  relieved,  five  showed  only  slight  improvement,  while  in  eight 
there  was  no  improvement.  In  a  few  cases  which  subsequently  came  to 
autopsy,  tuberculous  lesions  were  discovered.  Cases  of  this  latter  type  can 
scarcely  be  classified  as  primary  dysmenorrhea,  inasmuch  as  definite  local 
pathological  conditions  were  present.  The  same  statement  may  be  made  con- 
cerning the  case  reported  by  Pfannenstiel,  in  which  rapid  miliary  tuber- 
culosis in  the  abdomen  followed  dilatation  of  the  cervix  by  laminaria  for  the 
relief  of  dysmenorrhea. 

Grafenberg  obtained  a  positve  tuberculin  reaction  in  twenty-one  of  thirty 
patients  who  had  applied  for  relief  from  primary  dysmenorrhea.  In  cases 
of  secondary  dysmenorrhea,  the  response  was  always  negative.  In  cases  of 
the  primary  group  the  genitalia,  according  to  Grafenberg,  are  always  under- 
developed. In  eleven  of  his  cases  there  was  also  a  local  reaction  in  the  geni- 
talia after  the  use  of  tuberculin.  These  findings  lead  him  to  believe  that  the 
defective  development  of  the  genital  organs  so  aften  associated  with  dys- 
menorrhea is  the  result  of  a  tuberculous  process  which  involves  the  pelvic 
organs  during  childhood,  later  undergoing  healing. 

In  a  similar  study  of  this  relationship,  Cotte  finds  that  the  majority  of 
women  who  suffer  with  tuberculosis  exhibit  dysmenorrhea.  In  a  series  of 
seventy  such  women  whom  he  treated  with  tuberculin,  he  reports  forty  as 
cured  of  the  dysmenorrhea.  He  considers  the  dysmenorrhea  as  definitely 
due  to  a  toxemia  of  tuberculous  origin.  Much  more  evidence  is  needed, 
however,  before  there  can  be  any  acceptance  of  the  views  of  either  Cotte 
or  Grafenberg. 

Other  Constitutional  Disorders.—  Among  the  other  constitutional 
disorders  with  which  dysmenorrhea  may  be  clinically  associated,  mention 
may  be  made  of  diabetes,  nephritis,  syphilis,  rheumatism,  gout,  and  chronic 
cardiac  disease. 

Dysmenorrhea  Due  to  Local  Pelvic  Disease. —  There  are  few  pelvic 
disorders  which  may  not  at  times  be  associated  with  dysmenorrhea.  In  an 
analysis  of  looo  cases  admitted  to  the  gynecological  wards  of  the  Johns 
Hopkins  Hospital,  omitting  those  in  which  menstruation  had  ceased  or  had 


DYSMENORRHEA  ,  201 

not  yet  begun,  Holdeii  found  that  dysmenorrhea  was  present  in  47  per  cent. 
This  series,  it  may  be  added,  included  also  those  patients  with  rectal,  renal, 
and  ureteral  disease.  In  about  23  per  cent  of  the  entire  number,  the  dys- 
menorrhea seemed  to  be  definitely  caused  by  certain  abnormal  conditions  of 
the  pelvic  organs.  In  22  per  cent,  it  was  present  in  conjunction  with  such 
conditions,  but  was  apparently  not  caused  by  them.  It  is  interesting  to  note 
that  in  about  90  per  cent  of  all  the  cases  of  secondary  dysmenorrhea,  the 
cause  is  to  be  found  in  one  of  three  conditions :  ( i )  retrodisplacements  of 
the  uterus;  (2)  pelvic  inflammatory  disease;  and  (3)  myomata  of  the 
uterus. 

Retrodisplacement  of  Uterus. —  This,  according  to  Holden,  is  the 
most  frequent  cause  of  dysmenorrhea,  accounting  for  fully  forty-one  per 
cent  of  the  cases.  Of  nulliparous  women  with  displacements  which  cause 
symptoms,  86  per  cent  suffer  with  dysmenorrhea.  In  the  cases  of  retro- 
displacement  which  occur  after  childbirth,  dysmenorrhea  is  much  less  com- 
mon. About  25  per  cent  of  the  nulliparae  have  dysmenorrhea  which  is 
apparently  caused  by  malposition.  In  an  analysis  of  176  cases  of  retro- 
version, Judd  found  that  59  per  cent  suffered  with  dysmenorrhea. 

Inflammatory  Disease  of  Pelvic  Organs. —  About  37  per  cent  of  the 
cases  of  dysmenorrhea  in  Holden's  series  were  found  to  be  due  to  inflam- 
matory disease  of  the  uterus,  tubes  or  ovaries.  In  the  majority  of  these, 
the  inflammation  was  of  a  chronic  type.  Endometritis,  contrary  to  the 
older  teaching,  is  an  infrequent  cause  of  dysmenorrhea.  This  is  not  sur- 
prising when  one  considers  the  comparative  infrequency  of  this  condition. 
Cullen,  for  example,  found  a  genuine  endometritis  in  only  forty-eight  of 
eighteen  hundred  microscopic  examinations  of  the  endometrium. 

As  regards  the  relation  of  pelvic  inflammatory  disease  to  dysmenorrhea, 
one  is  frequently  struck  with  the  disparity  between  the  pathological  findings 
in  the  pelvis  and  the  degree  of  menstrual  pain  of  which  the  patient  com- 
plains. It  is  remarkable  how  much  trouble  may  exist  in  the  pelvis  in  women, 
compatibly  with  a  fair  measure  of  comfort.  Not  infrequently  bimanual 
examination  may  show  the  presence  of  large  pus  tubes,  while  little  or  no 
dysmenorrhea  or  pelvic  pain  is  complained  of  by  the  patient.  On  the  other 
hand,  a  catarrhal  salpingitis,  with  very  little  enlargement  of  the  tubes,  may 
give  rise  to  extremely  severe  pain  with  the  periods. 

I  may  cite  the  case  of  a  young  woman  who  came  under  my  observation, 
and  who  complained  of  intense  pain  at  each  menstrual  period.  Bimanual 
examination  failed  to  reveal  any  very  definite  pelvic  disease.  She  had 
already  passed  through  the  hands  of  two  competent  gynecologists  and  had 
been  dismissed  as  a  neurasthenic.  The  severity  of  the  pain  led  me,  in  con- 
sideration of  the  patient's  apparently  well  balanced  nervous  system,  to 
advise  operation,  in  spite  of  the  absence  of  palpable  pelvic  disease.  Double 
chrordc  salpingitis  was  found,  the  moderately  thickened  tubes  being  adherent 
very  high  up  near  the  brim  of  the  pelvis,  so  that  they  were  difficult  to  out- 


202  MENSTRUATION  AND  ITS  DISORDERS 

line  through  the  rather  thick  abdominal  wall,  even  under  anesthesia. 
Removal  of  the  diseased  tubes  cured  the  dysmenorrhea. 

jMyomata  of  Uterus. —  In  the  series  studied  by  Holderi,  myomata  were 
found  to  be  the  cause  of  dysmenorrhea  in  1 1  per  cent.  Kelly  has  also  col- 
lected the  records  of  two  hundred  cases  of  myoma,  under  the  age  of  forty- 
five,  from  the  Johns  Hopkins  Hospital,  for  the  purpose  of  determining  the 
frequency  of  dysmenorrhea  with  this  condition.  Ninety-four  of  his  cases 
were  white  and  one  hundred  and  six  colored.  He  found  that  in  25  per  cent 
dysmenorrhea  had  been  noted  since  the  onset  of  the  patient's  trouble.  He 
alludes  to  a  similar  study  made  some  years  previously,  in  which  dysmenor- 
rhea was  observed  in  20  per  cent  of  the  cases. 

As  might  be  expected,  dysmenorrhea  is  much  more  frequently  encoun- 
tered with  myomata  of  the  submucous  or  interstitial  type  than  with  the 
subperitoneal  variety.  This  is  obviously  due  to  the  fact  that  myomata  of 
the  first  two  varieties  are  especially  apt  to  excite  expulsive  uterine  contrac- 
tions, and  at  the  same  time  are  more  frequently  a,ssociated  with  congestion 
of  the  uterine  mucosa  and  muscularis. 

Other  Forms  of  Pelvic  Disease. —  From  the  study  of  Holden  it  would 
appear  that  about  1 1  per  cent  of  all  cases  of  dysmenorrhea  were  caused  by 
various  forms  of  pelvic  disease  other  than  the  three  important  groups 
already  discussed.  It  is  scarcely  necessary  to  enumerate  these  remaining 
possible  causes  of  dysmenorrhea,  inasmuch  as  they  embrace  practically  all 
the  usual  forms  of  pelvic  disease,  such  as  polypi,  cystic  or  solid  tumors  of 
the  ovary,  carcinoma,  etc. 

CLINICAL  CHARACTERISTICS  OF  DYSMENORRHEA 

Clinical  Types. —  Pain  of  any  kind  is  a  purely  subjective  symptom, 
and  is  therefore  subject  to  the  widest  individual  variations.  This  is  pre- 
eminently true  of  pain  at  the  time  of  menstruation.  It  is  necessary  only  to 
mention  the  principal  types  of  pain  experienced  by  women  at  the  time  of 
menstruation,  bearing  in  mind  that  numerous  factors  may  operate  to  modify 
these  types  in  one  way  or  another.  The  great  majority  of  cases  of  dysmen- 
orrhea may  be  classified  under  one  of  the  two  principal  types  distinguished 
by  Kelly,  i.  e.,  the  spasmodic  or  the  congestive  forms. 

Spasmodic  Dysmenorrhea. —  This  is  well  typified  in  those  very  fre- 
quent cases  of  primary  dysmenorrhea  seen  in  nulliparous  young  women, 
often  associated  with  scanty  menstruation  and  frequently,  in  married 
women,  with  sterility.  Such  women,  in  the  interval  between  menses,  may 
enjoy  perfect  health.  One  or  sometimes  two  days  before  the  onset  of  men- 
struation, however,  they  begin  to  suffer  with  severe  spasmodic  pains  in  the 
pelvis.  Sometimes  the  spasmodic  character  of  the  pain  is  conspicuous,  so 
that  the  comparison  to  miniature  labor  pains  is  justified. 

In  other  cases,  the  pain  is  somewhat  less  intermittent.  It  often 
radiates  toward  the  back  or  down  the  lower  limbs.  It  may  be  associated 
with  nausea  or  vomiting,  suggesting  a  toxic  origin.     In  neurotic  individuals 


DYSMENORRHEA  203 

there  may  be  well  marked  nervous  symptoms.  In  some  cases  these  take  the 
form  of  depression,  in  others,  especially  those  of  hysterical  tendencies,  there 
may  be  marked  excitability,  and  perhaps  even  convulsions. 

The  pain  continues  with  greater  or  less  severity  until  the  flow  is  well 
established,  when  it  usually  abates,  sometimes  quite  suddenly.  While  the 
pain  commonly  ceases  after  the  first  day  of  the  bleeding,  it  may  continue 
longer,  and  perhaps  throughout  the  entire  period. 

Congestive  Dysmenorrhea. —  While  this  form  of  pain  is  sometimes 
encountered  in  primary  dysmenorrhea,  it  is  more  frequent  in  cases  of  the 
secondary  type.  The  time  at  which  it  appears  is  subject  to  wide  variation. 
It  may  begin  as  much  as  a  week  before  the  onset  of  the  menstrual  period, 
or  it  may  not  occur  until  the  first  day  of  the  flow.  Occasionally,  as  a  matter 
of  fact,  it  is  only  toward  the  end  of  the  menses  that  pain  is  complained  of. 
Efforts  to  correlate  the  time  of  appearance  of  the  dysmenorrhea  with  the 
type  of  pelvic  lesion  have  not  been  very  satisfactory. 

The  pain  is  usually  of  a  dull,  dragging,  or  bearing  down  character.  In 
secondary  dysmenorrhea  it  is  often  more  marked  on  one  side  than  on  the 
other,  and  may  be  perceived  on  one  side  only.  Usually,  of  course,  this  is 
the  side  of  the  pelvic  disease,  although  this  is  not  an  invariable  rule.  Fre- 
quently the  pain  in  the  iliac  regions  is  accompanied  by  backache,  and  perhaps 
by  pain  in  the  limbs. 

Other  symptoms  may  be  associated,  such  as  headache,  nervous  irritability, 
and  digestive  disorders,  together  with  the  various  manifestations  of  the 
causative  pelvic  disease. 

TREATMENT  OF  DYSMENORRHEA 
General  Considerations. —  The  relief  of  menstrual  pain  during  a  spe- 
cific attack  of  dysmenorrhea  is  usually  simple  enough,  consisting  in  the  mere 
relief  of  pain.  The  radical  treatment  of  dysmenorrhea,  however,  looks  to 
permanent  relief  from  pain  at  the  menstrual  periods.  The  treatment  of 
dysmenorrhea  may  therefore  logically  be  considered  under  two  heads  :  ( i ) 
symptomatic  treatment  of  dysmenorrhea  during  an  attack;  and  (2)  treat- 
ment for  permanent  relief  of  the  dysmenorrhea. 

Treatment  During  Attack. —  General  Measures. —  Except  in  the 
milder  grades  of  dysmenorrhea,  rest  in  bed  is  of  great  importance  in  the 
relief  of  the  pain.  When  the  dysmenorrhea  is  severe,  it  is  usually  unneces- 
sary to  enjoin  this,  as  the  patient  takes  to  bed  of  her  own  accord.  In  the 
mild  forms  of  dysmenorrhea,  rest  in  bed  is  frequently  all  that  is  necessary 
to  relieve  the  pain.  When  the  condition  is  more  sev^ere,  however,  other 
measures  are  necessary.  The  bowels  should  be  well  evacuated.  When  the 
pain  is  quite  severe,  a  hot  water  bag  to  the  lower  abdomen  often  gives 
much  relief. 

Drugs. —  The  drugs  which  have  been  employed  in  the  treatment  of  dys- 
menorrhea are  legion.  Among  the  most  valuable  I  would  place  the  various 
coal  tar  derivatives,  such  as  phenacetin,  acetanilid  and  antipyrin.     Of  these, 


204  MENSTRUATION  AND  ITS  DISORDERS 

phenacetin  is  perhaps  the  most  desirable,  since  it  is  the  least  depressing. 
In  administering  any  of  these  drugs,  due  regard  must  be  paid  to  the  con- 
dition of  the  patient's  heart,  and  caffein  should  be  combined  with  the 
analgesic.  Either  of  the  following  simple  prescriptions  will  be  found 
serviceable  in  many  cases : 

19     Acetphenetidin 3  i 

Caffeinae gr.  vi 

Sod.  bicarbonat.  q.  s §  ii 

M.  et  div.  in  chart,  no.  xii. 

Sig.     One  powder  with  water  q  3  hours. 

^     Acetanilidi gr.  xlv 

Caffeinae gr.  vii  ss 

M.  et  div.  in  caps.  no.  xv. 

Sig.     One  capsule  every  three  hours. 

Closely  allied  with  the  coal  tar  derivatives  are  such  drugs  as  aspirin  (ac. 
acetylsalicylic)  and  pyramidon  (dimethylaminantipyrin).  The  former 
may  be  prescribed  in  tablet  form  in  doses  of  five  grains  every  four  hours. 
Pyramidon  is  best  given  in  capsule  form  in  doses  of  three  to  six  grains  every 
four  hours. 

Occasionally  the  pain  is  so  severe  that  it  may  be  necessary  to  add  small 
doses  of  codein  to  any  of  the  above  drugs,  as  in  the  following  prescriptions : 

I^     Acetanilidi gr.  xlv 

Caffeinae gr.  vii  ss 

Codein.  sulphat gr-  iii 

M.  et  div.  in  caps.  no.  xv. 

Sig.     One  capsule  every  three  or  four  hours. 

According  to  Matthews  Duncan,  the  best  drug  in  the  treatment  of  dysmen- 
orrhea is  guaiacum,  given  in  doses  of  ten  grains  three  times  a  day,  beginning 
a  week  before  the  onset  of  menstruation. 

The  two  drugs,  however,  which  are  most  efficacious  in  relieving  the  pain 
of  dysmenorrhea  both  possess  such  serious  disadvantages  that  they  should 
rarely,  if  ever,  be  employed.  I  have  reference  to  morphin  and  alcohol.  The 
administration  of  either  is  attended  with  the  risk  of  habituation  to  their  use, 
especially  when  they  are  used  in  the  treatment  of  such  a  regularly  recurring 
trouble,  as  dysmenorrhea  so  frequently  is.  In  rare  instances,  where  the 
cramp-like  pains  are  very  severe,  opium  may  be  given  guardedly,  as  in  the 
following  prescription  recommended  by  Hirst: 

I^     Tinct.  opii.  camph §  i 

Tinct.  zingib §  i 

Spir.  chloroform 3  ii 

Syrup  acac §  ss 

Aq.  menth.  piper,  qs.  ad %  iv 

M. 

Sig.     One  tablespoonful  when  required  for  cramps. 


DYSMENORRHEA  205 

I  have  often  obtained  quick  results  from  the  use  of  belladonna,  in  sup- 
positories containing  a  half  grain  of  the  extract.  In  severe  cases,  the 
extract  of  opium,  in  doses  of  a  c^uarter  of  a  grain,  may  be  combined  with 
the  belladonna. 

In  cases  characterized  by  marked  nervous  symptoms,  it  is  usually  advis- 
able to  resort  to  the  administration  of  bromids.  Since  there  is  very  little 
pain  relieving  virtue  in  the  bromids  themselves,  they  must  usually  be 
combined  with  some  more  decidedly  analgesic  drug. 

A  number  of  vegetable  drugs  have  been  credited,  probably  wrongly,  with, 
more  or  less  efficacy  in  relieving  dysmenorrhea.  Among  these  apiol  is  per- 
haps the  best  known.  Its  principal  indication  would  seem  to  be  in  those  cases 
of  dysmenorrhea  associated  with  scantiness  of  the  flow.  It  is  administered 
in  doses  O'f  from  three  to  six  minims  three  or  four  times  a  day.  On  account 
of  its  disagreeable  taste,  it  is  best  given  in  capsules. 

Still  another  drug  often  employed,  though  of  doubtful  value,  is  viburnum 
prunifolium,  in  the'  form  of  the  fluidextract,  which  may  be  given  in  doses 
of  twenty  minims  to  one  dram.  The  National  Formulary  includes  a  prep- 
aration, the  elixir  of  viburnum  prunifolium  (elixir  viburni  prunifolii), 
which  is  given  in  doses  of  one  dram,  and  which  is  much  less  disagreeable 
than  the  official  fluidextract.  Certainly,  if  this  drug  is  employed  at  all, 
there  is  no  need  to  resort  to  the  various  proprietary  preparations  which  have 
such  wide  vogue,  and  which  in  addition  to  viburnum  prunifolium  contain 
usually  an  array  of  little  known  drugs  with  long  sounding  names,  but  which 
are  therapeutically  worthless, 

Hydrastis  is  another  drug  often  resorted  to  in  the  treatment  of  dysmenor- 
rhea. The  fluidextract  is  the  best  form  in  which  to  administer  it,  the  dose 
being  from  ten  to  thirty  minims,  given  well  diluted  in  water. 

Some  of  the  most  widely  used  of  the  proprietary  mixtures  purport  to 
depend  for  their  antidysmenorrheic  properties  upon  the  presence  of  such 
drugs  as  helonin.  It  has  been  demonstrated,  however,  that  the  therapeutic 
effect  of  this  drug  is  practically  nil.  Incidently,  the  preparations  in  question 
contain  a  large  proportion  of  alcohol.  When  one  considers  that  the  dose  rec- 
ommended in  severe  dysmenorrhea  is  often  a  teaspoonful  every  ten  or  fifteen 
minutes,  it  can  he  readily  understood  that  any  relief  which  such  a  prepara- 
tion affords  is  probably  to  be  attributed  to  the  alcohol  it  contains.  The 
dangers  of  prescribing  such  remedies  are  obvious. 

A  number  of  other  drugs  have  been  used  in  the  treatment  of  painful  men- 
struation. Many  of  them  are  of  doubtful  efficacy,  but  some  are  even  now 
quite  extensively  used.  Thus  may  be  mentioned  cannabis  indica,  in  doses 
of  twenty  or  thirty  drops  of  the  tincture ;  Pulsatilla,  in  doses  of  three  minims 
of  the  fluidextract ;  piscidia  erythema,  in  doses  of  one  half  to  tw^o  drams  of 
the  fluidextract  (Hare),  and  gelsemium  in  doses  of  ten  or  fifteen  minims 
of  the  tincture. 

The  Atropin  Treatment  of  Spasmodic  Dysmenorrhea. —  The  em- 
ployment of  atropin  in  the  treatment  of  spasmodic  dysmenorrhea  is,  in  my 


206  MENSTRUATION  AND  ITS  DISORDERS 

opinion,  entitled  to  the  emphasis  of  special  consideration.  Unlike  the  other 
drugs  which  have  been  enumerated,  atropin  seems  to  fulfill  a  real  indication, 
other  than  the  mere  relief  of  the  symptom  of  pain.  The  form  of  dysmenor- 
rhea in  which  atropin  is  of  value  is  the  spasmodic,  which  is  observed  so 
characteristically  in  young  nuUiparous  women,  and  which  is  frequently 
associated  with  scanty  menstruation,  and  sometimes  with  sterility.  We 
are  all  familiar  with  the  clinical  picture  of  such  cases.  The  use  of  atropin 
in  the  treatment  of  this  form  of  dysmenorrhea  is  based  on  the  fact  that 
it  diminishes  the  irritability  of  the  autonomic  nerve  endings  in  the 
uterus.  In  19 lo,  Drenkhahn  reported  remarkable  results  from  the  injection 
of  a  solution  of  atropin  directly  into  the  cervical  canal  ( i  mg.  of  atropin  in 
I  c.cm.  of  water).  If  a  speculum  or  syringe  be  not  at  hand,  he  advised  the 
introduction  of  a  tampon  saturated  with  atropin  solution  ( i  per  cent 
strength).  This  plan  of  treatment,  Drenkhahn  states,  he  had  followed  for 
fifteen  years,  basing  it  originally  on  the  experimental  work  of  Schindler, 
who  showed  that  atropin  has  a  direct  action  on  the  uterine  muscle. 

The  method  was  taken  up  by  Novak,  of  Vienna,  who  was  struck  by  the 
fact  that  many  women  with  increased  irritability  of  the  autonomic  nerve 
system  suffer  with  dysmenorrhea.  In  accordance  with  the  Krdmpftheorie, 
he  suggested  that  the  dysmenorrhea  is  due  to  the  increased  irritability  of  the 
autonomic  nerve  endings  in  the  uterus.  Novak  administers  the  atropin  in 
pills  containing  0.5  mg.  each,  three  being  given  each  day,  beginning  just 
before  the  expected  onset  of  menstruation.  His  preference  for  the  admin- 
istration of  the  drug  by  mouth  is  a  wise  one,  for  the  results  appear  to 
be  just  as  satisfactory  as  by  Drenkhahn's  method,  while  he  thus  avoids  the 
slight  danger  of  infection  associated  with  the  latter.  Novak's  method  is 
obviously  less  disagreeable,  especially  in  the  case  of  virgins. 

Thirty-eight  cases  were  reported  by  Novak,  in  thirty  of  which  the  results 
were  distinctly  favorable.  All  these  patients  had  suffered  with  "  crampy  " 
pains,  except  one  in  whom  the  pain  was  rather  continuous,  and  one  in  whom 
the  character  of  the  pain  is  not  mentioned.  In  the  thirty  favorable  cases 
the  pain  either  disappeared  entifely  or  else  became  insignificant.  The  less 
characteristic  symptoms  which  so  frequently  accompany  the  spasmodic 
pain — •backache,  bearing  down  in  the  lower  abdomen,  general  lassitude, 
etc.  —  were  not  influenced  by  the  atropin,  which  seemed  to  exert  a  special 
effect  on  the  colicky  pains.  In  one  case  the  result  was  rather  indefinite, 
the  patient  being  better,  but  not  strikingly  so.  In  seven  cases  the  treatment 
failed  to  relieve  the  pain.  Among  these  seven  were  the  two  mentioned 
above  as  atypical,  that  is,  not  suffering  with  the  spasmodic  pains  of  typical 
"  menstrual  colic." 

Novak  is  inclined  to  believe  that  failures,  when  they  occur,  are  due  to 
insufficient  dosage.  This  would  seem  to  be  in  conformity  with  the  experi- 
mental work  of  Kehrer,  who  found  that  in  small  doses  atropin  stimulates 
the  uterine  muscle,  while  in  large  doses  it  inhibits  it. 

Stolper,  who  has  also  employed  the  atropin  method  in  a  large  number  of 


DYSMENORRHEA  207 

cases,  offers  a  different  explanation  for  the  failures  which  occur  in  a  certain 
proportion  of  cases.  He  asserts  that  atropin  is  very  efficient  in  those  cases 
in  which  the  dysmenorrhea  is  accompanied  by  other  vagotonic  symptoms. 
In  a  certain  number  of  dysmenorrheics,  however,  vagotonic  symptoms  are 
absent,  and,  according  to  Stolper,  there  may  even  be  symptoms  indicating 
a  heiglitened  irritability  of  the  sympathetic  system  (sympathicotony).  As 
a  means  of  clinical  tliffcrentiation  between  these  two  groups,  he  lays  much 
stress  on  a  study  of  the  blood  pressure.  He  lays  down  the  rule  that  women 
with  a  normal  or  slig'htly  raised  blood  pressure  react  most  promptly  to 
atropin,  while  when  the  blood  pressure  is  greatly  raised  there  is  apt  to  be  no 
response  to  the  administration  of  atropin.  The  blood  pressure  must  be 
measured  in  the  intermenstrual  interval,  not  during  menstruation  or  during 
the  premenstrual  period.  Stolper,  I  may  add,  administers  the  drug  either 
in  suppositories  (o.ooi  gm.)  or  by  subcutaneous  injection  (0.00075  fen^-)- 

My  own  experience  with  the  atropin  treatment  of  spasmodic  dysmenor- 
rhea has  been  most  encouraging.  In  the  frequent  cases  of  young  unmarried 
women  in  whom  pelvic  examination  is  obviously  undesirable,  and  who 
present  the  classic  picture  of  spasmodic  pain  recurring  with  each  menstrua- 
tion, the  atropin  treatment  is  indicated  without  the  preliminary  of  pelvic 
examination.  In  my  own  cases  I  have  followed  the  plan  of  Novak,  though 
I  have  frequently  administered  somewhat  larger  doses  than  those  recom- 
mended by  him.  My  experience  has  been  that  the  cases  which  respond  most 
favorably  are,  speaking  generally,  those  in  which  the  atropin  has  been 
pushed  to  the  point  of  tolerance.  The  plan  has  been  to  commence  the 
administration  of  the  drug  about  two  days  before  menstruation  is  expected 
to  appear,  and  to  continue  its  use  until  the  second  or  third  day  of  menstrua- 
tion, depending  on  the  usual  duration  of  the  pain.  Patients  differ,  of  course, 
in  the  degree  of  tolerance  to  the  drug.  Ordinarily,  about  i/ioo  grain  is 
given  three  times  a  day,  unless  some  pain  appears,  in  which  event,  if  there 
are  no  symptoms  of  atropin  saturation,  the  doses  may  be  given  somewhat 
more  frequently.  Many  patients  complain  of  dryness  of  the  throat,  itching 
of  the  skin,  and  sometimes  even  disturbed  accommodation,  in  which  case  it 
may  be  necessary  to  lessen  the  dosage  somewhat.  When  it  is  desired  to 
study  the  effect  of  the  atropin  on  dysmenorrhea,  it  is  best  to  administer  it 
alone,  as  in  tablet  form.  In  some  cases,  however,  I  have  combined  it  with 
various  other  drugs  of  analgesic  nature,  such  as  aspirin.  Other  than  the 
occasional  symptoms  due  to  overstepping  the  patient's  atropin  tolerance,  I 
have  observed  no  bad  results  of  any  kind. 

The  results  in  the  cases  of  spasmodic  dysmenorrhea  which  I  have  treated 
with  atropin  have  been  very  encouraging  —  so  much  so  as  to  impel  me  to 
further  employment  of  the  method.  While  there  have  been  some  failures, 
there  have  been,  on  the  other  hand,  some  strikingly  successful  results.  For 
the  failures  I  have  no  explanation  to  suggest  other  than  those  quoted  above 
from  Novak  and  Stolper.  It  is  hardly  necessary  to  add,  in  conclusion,  that 
it  would  be  illogical  to  expect  good  results  from  the  administration  of 


208  MENSTRUATION  AND  ITS  DISORDERS 

atropin  in  cases  of  dysmenorrhea  associated  with  definite  pathologic  lesions 
in  the  uterus  or  adnexa.  In  such  cases  the  logical  treatment  of  the  menstrual 
pain  is  the  removal  or  treatment  of  the  causative  lesion. 

Treatment  by  Benzyl  Benzoate. —  Recently  Macht  has  urged  the  use 
of  benzyl  benzoate  as  an  antispasmodic  in  a  number  of  diseases,  including 
uterine  colic.  Litzenberg  has  reported  favorably  on  this  plan  of  treatment 
in  a  series  of  cases  of  spasmodic  dysmenorrhea.  The  mode  of  action  of  the 
benzyl  benzoate  is  stated  to  be  similar  to  that  of  atropin,  the  advantage  over 
the  latter  lying  in  its  non-toxicity.  Benzyl  benzoate  is  administered  in  the 
form  of  an  alcoholic  solution  in  doses  of  twenty  to  thirty  drops  every  four 
hours,  although  considerably  larger  doses  are  believed  to  be  safe  by  Litzen- 
berg. To  avoid  the  rather  disagreeable  taste  of  such  a  solution,  Litzenberg 
recommends  the  use  of  the  aromatic  elixir  of  eriodictyon  as  a  vehicle.  He 
employs  the  following  formula : 

Benzyl  benzoate   lo  gms. 

Mucilage  of  acacia 5  gms. 

Aromatic  elixir  of  eriodictyon 35  gms. 

Sig.    Give  from  one  half  to  two  teaspoonf uls,  according  to  necessity. 

The  Mammary  Treatment  of  Dysmenorrhea. —  In  1907  Polano,  on 
the  theory  that  the  ovaries  and  mammae  are  antagonistic  in  their  physio- 
logical activities,  suggested  the  treatment  of  dysmenorrhea  by  inducing 
hyperemia  of  the  breasts.  When  the  latter  are  doing  extra  work,  as  during 
pregnancy  and  the  puerperium,  the  ovaries  are  resting.  The  physiologic 
work  of  an  organ  is  dependent  on  its  blood  supply,  and  the  method  of  Polano 
aims  to  bring  about  overfunction  of  the  breast  by  means  of  suction  hyper- 
emia. He  thus  seeks  to  give  the  ovaries  rest.  He  claims  that  the  results 
of  the  treatment  have  been  surprisingly  good  in  a  number  of  cases  which 
had  showed  no  benefit  under  other  plans  of  treatment. 

A  few  days  before  the  menstrual  period  is  due  a  suction  glass  is  applied 
to  each  breast,  as  in  the  treatment  of  mastitis.  The  air  is  aspirated  with  a 
syringe  until  the  breast  is  drawn  out,  stopping  short  at  the  slightest  pain. 
The  glass  is  left  in  place  for  half  an  hour,  removing  and  replacing  it  once 
during  this  time.  The  same  procedure  is  carried  out  each  day  until  the  end 
of  the  menstrual  period.  The  hyperemia  of  the  breast  usually  persists  for 
some  hours  after  the  removal  of  the  cup.  This  plan  of  treatment,  according 
to  Polano,  not  only  relieves  the  dysmenorrhea,  but  also  shortens  the  duration 
of  the  flow. 

This  plan  of  treating  dysmenorrhea  has  not  attained  very  wide  adoption, 
and  the  few  reports  dealing  with  it  would  indicate  that  its  results  are 
certainly  not  very  striking. 

Measures  for  Permanent  Relief  of  Dysmenorrhea. —  The  many  plans 
of  treatment  which  have  in  the  past  been  advocated  in  the  treatment  of  this 
troublesome  symptom  indicate  that  none  has  been  eminently  successful. 
This  is  especially  true  of  primary  dysmenorrhea,  the  treatment  of  which 


DYSMENORRHEA  209 

still  remains  one  of  the  important  unsolved  problems  of  gynecology.  The 
fact  that  even  hysterectomy  has  at  times  been  resorted  to,  shows  to  w^hat 
desperate  straits  gynecologists  are  sometimes  driven  in  the  management  of 
such  cases.  The  treatment  of  the  two  types  of  dysmenorrhea  is  quite 
different,  and  will  be  considered  separately. 

Measures  for  Permanent  Cure  of  Primary  Dysmenorrhea. —  The 
physiological  cure  of  primary  dysmenorrhea  is  pregnancy.  It  is  a  well- 
known  fact  that  this  practically  always  marks  the  permanent  disappearance 
of  primary  dysmenorrhea.  Even  v^hen  pregnancy  does  not  take  place,  it  is 
a  common  observation  that  marriage  sometimes  brings  great  relief  from  this 
symptom,  probably  because  the  relations  of  married  life  act  as  a  stimulant  to 
the  development  of  the  uterus.  Unfortunately,  marriage  cannot  always  be 
prescribed  with  as  much  readiness  as  medicine.  At  any  rate,  the  suffering  and 
inconvenience  of  the  patient  are  often  so  marked  that  measures  looking  for 
radical  relief  must  be  considered. 

Importance  of  Accurate  Diagnosis. —  In  all  cases,  it  need  scarcely  be 
emphasized,  it  is  of  the  greatest  importance  to  assure  oneself  that  the 
dysmenorrhea  is  actually  of  the  primary  type,  i.  e.,  that  there  is  no  patho- 
logical condition  in  the  pelvis  which  may  be  responsible  for  the  pain.  This 
can  often  be  ascertained  only  by  careful  examination  under  anesthesia. 
Whenever  it  is  decided  to  anesthetize  the  patient  for  the  purpose  of  such 
an  examination,  it  is  wise  to  prepare  for  dilatation  of  the  cervix  should  no 
anatomic  cause  be  found  for  the  dysmenorrhea,  so  that  the  patient  may  be 
spared  the  inconvenience  and  risk  of  repeating  the  anesthetic. 

Dilatation  of  Cervix  by  Rapid  Method. —  This  still  remains  the  most 
popular  method  of  treating  dysmenorrhea  of  the  type  now  under  discussion. 
This  plan  of  treatment  is  of  course  based  primarily  upon  the  conception  that 
dysmenorrhea  is  obstructive  in  origin.  As  has  already  been  shown,  how- 
ever, there  can  be  little  doubt  of  the  fallacy  of  this  theory.  On  the  other 
hand,  there  can  be  no  question  that  dilatation  of  the  cervical  canal  is  often 
followed  by  relief  from  dysmenorrhea,  sometimes  permanent,  more  often 
temporary. 

In  former  years,  dilatation  was  usually  accompanied  by  curettage  of  the 
uterus.  In  the  majority  of  cases,  however,  there  is  no  real  indication  for 
the  curettage,  and  nothing  is  gained  by  its  performance.  Microscopic  exam- 
ination of  the  endometrium  from  such  cases  practically  always  reveals  a 
normal  structure. 

Holden  has  analyzed  the  reports  received  from  95  patients  at  periods 
varying  from  one  to  twelve  years  after  dilatation  and  curettage  for  dysmen- 
orrhea. He  finds  that  40  per  cent  were  entirely  or  very  greatly  relieved 
for  at  least  one  year,  with  7  per  cent  of  this  40  per  cent  having  a  recurrence 
after  one  year  or  more ;  30  per  cent  had  no  relief  at  all,  while  the  remaining 
30  per  cent  had  but  slight  relief  or  relief  for  a  few  months  only.  Marked 
maldevelopment  of  the  pelvic  organs  was  present  in  20  cases,  and  in  only 
25  per  cent  of  these  were  the  patients  relieved. 


210  MENSTRUATION  AND  ITS  DISORDERS 

From  a  study  of  the  clinical  character  of  the  pain  experienced  by  the 
patients  in  these  cases,  Holden  concludes  that  the  prognosis  for  relief  by 
dilatation  and  curettage  is  better  when  the  pains  are  sharp  and  spasmodic. 
It  is  bad  when  the  pains  are  dull.  The  statistics  of  Norris  and  Barnard 
give  about  the  same  results  as  those  of  Holden. 

A  description  of  the  technic  of  the  operation  of  rapid  dilatation  of  the 
cervical  canal  is  not  within  the  scope  of  the  present  work.  It  may  be  found 
in  any  of  the  works  dealing  with  operative  gynecology.  It  should  be  em- 
phasized, however,  that  the  dilatation  should  be  as  thorough  as  possible  in 
order  to  insure  good  results.  Even  then,  unfortunately,  there  may  be  no 
relief  from  the  menstrual  pain.  In  other  cases,  as  the  above  statistics  indi- 
cate, the  relief  is  temporary,  so  that  it  is  frequently  necessary  to  repeat  the 
procedure.  Since  it  seems  to  have  been  demonstrated  that  the  mere  widen- 
ing of  the  cervical  canal  cannot  explain  the  relief  of  the  pain,  it  is  probable 
that  the  good  results  of  the  operation  in  many  instances  are  due  to  its 
stimulating  effect  upon  the  development  of  the  uterus. 

Continuous  Dilatation  by  Stem  Pessaries. —  In  order  that  dilatation 
of  the  cervix  may  be  maintained  more  or  less  continuously,  the  use  of  various 
forms  of  stem  pessaries  is  advocated  by  some.  This  measure  is  employed 
usually  as  a  supplement  to  an  initial  rapid  dilatation  of  the  canal.  Carstens, 
who  has  been  especially  enthusiastic  concerning  the  value  of  the  stem  pes- 
sary, explains  its  good  effect  by  its  irritant  action  on  the  uterus,  causing 
contraction  and  thereby  giving  the  uterine  muscle  exercise,  and  causing  it  to 
develop  like  other  muscles  which  are  properly  exercised.  In  other  words, 
the  pessary  acts  as  a  foreign  body,  causing  efforts  on  the  part  of  the  uterus 
1o  expel  it.     The  pessary  used  by  Carstens  is  the  Chambers  pessary. 

Even  more  popular  than  the  latter  has  been  the  use  of  the  Wylie 
drain.  This  is  a  bulbous  stem  with  a  lateral  drain,  which  permits  of  free 
drainage  of  the  uterine  cavity.  The  pessary  is  introduced  into  the  uterus, 
following  a  thorough  dilatation  of  the  cervical  canal.  This  should,  by 
preference,  be  performed  about  a  week  before  the  onset  of  a  menstrual 
period.  It  is  usually  advisable  to  pack  the  vagina  lightly  after  introduc- 
ing the  pessary  into  the  uterus,  so  as  to  keep  it  from  falling  out  immediately 
after  the  dilatation,  when  the  cervix  is  of  course  very  wide.  It  is  even 
better  to  suture  the  pessary  to  the  cervix  with  silk  of  silkworm  gut.  The 
patient  should  be  kept  in  bed  for  a  day  or  two.  The  instrument  may  be  left 
in  for  a  period  of  usually  two  months. 

The  principal  objection  which  has  been  urged  against  the  use  of  the  stem 
pessary  is  the  fact  that  it  may  cause  a  troublesome  endocervicitis  and  perhaps 
actual  ulceration.  I  have  seen  cervical  infection  as  a  result  of  the  stem 
pessary.  It  is  also  stated  that  the  drainage  groove  in  the  pessary  may  be 
blocked  up,  so  that  the  pessary  acts  as  a  plug  rather  than  as  a  drain. 

While  these  objections  are,  to  my  mind,  well  founded,  it  is  only  fair  to 
say  that  these  complications  appear  to  be  far  less  frequent  than  one  might 
expect.     Moreover,  those  who  have  used  the  stem  pessary  extensively  are 


DYSMENORRHEA  211 

as  a  rule  enthusiastic  concerning  this  plan  of  treatment.  Beyea,  for  ex- 
anij^jle,  reports  that  22  of  26  single  women  in  whom  the  Wylie  drain  had 
been  used  had  been  entirely  relieved  of  menstrual  pain,  2  were  benefited  but 
still  had  considerable  pain,  and  2  received  no  benefit.  In  the  same  way, 
12  of  15  married  women  were  relieved  and  3  received  no  benefit.  Of  the 
15  married  women,  5  became  pregnant  after  operation,  3  going  to  full  term. 

Plastic  Operations  on  Cervix. —  A  number  of  surgical  procedures 
have  been  recommended  and  practiced  for  the  relief  of  dysmenorrhea,  on 
the  assumption  that  it  is  due  to  cervical  stenosis.  The  principal  operations 
of  this  class  are  those  devised  by  Dudley  and  Pozzi.  The  first  of  these, 
which  is  practically  the  same  as  that  suggested  by  Sims,  consists  in  splitting 
up  the  posterior  lip  of  the  cervix  as  far  as  the  internal  os,  and  then  suturing 
the  mucosa  of  the  cervical  canal  to  that  covering  the  pars  vaginalis. 

The  operation  of  Pozzi  consists  in  first  making  an  incision  laterally  out- 
ward from  the  cervical  canal  through  the  cervical  walls.  A  triangular  piece 
is  then  resected  from  the  centre  of  each  of  the  four  raw  surfaces  made  by 
the  two  incisions.  The  mucosa  of  the  lumen  is  then  sutured  to  that  of  the 
outer  surface  of  the  cervix,  thus  covering  the  four  raw  surfaces  and  leaving 
the  lumen  of  the  cervical  canal  widely  gaping. 

Aside  from  the  fact  that  these  operations  are  based  upon  a  faulty  concep- 
tion of  the  etiology  of  the  dysmenorrhea,  such  procedures  are  open  to  the 
objection  that  they  may  increase  the  difficulty  of  labor  in  the  event  that 
pregnancy  should  later  occur.  My  own  limited  experience  with  such  opera- 
tions has  not  made  me  very  enthusiastic  in  their  employment.  In  fact,  I 
have  abandoned  their  use.  While  favorable  results  are  reported  by  a 
number  of  observers,  there  is  little  prospect  that  these  operative  procedures 
will  ever  become  any  more  popular  than  they  now  are. 

The  Permanent  Cure  of  Secondary  Dysmenorrhea. —  The  permanent 
relief  of  this  form  of  dysmenorrhea  is  of  course  dependent  upon  the  removal 
or  correction  of  the  pelvic  disease  which  is  causing  it.  In  some  cases  the 
removal  of  a  myoma,  an  ovarian  cyst,  or  a  pyosalpinx  may  be  necessary; 
in  others,  the  correction  of  a  retrodisplacement ;  and  so  on.  The  technic  of 
the  various  operations  which  may  be  necessary  for  the  relief  of  secondary 
dysmenorrhea  is  discussed  in  the  various  text  books  of  operative  gynecology. 

MEMBRANOUS  DYSMENORRHEA 
General  Considerations. —  There  is  a  form  of  dysmenorrhea,  usually 
severe  and  cramp-like,  in  which  the  patient  passes  large  or  small  pieces  of 
membrane  with  the  menstrual  discharge.  To  this  form  the  designation  of 
membranous  dysmenorrhea  is  given.  The  first  description  of  the  condition 
is  usually  credited  to  Morgagni,  who  reported  a  case  in  his  "  De  Sedibus  et 
Causis  MorboTum  "  (1779).  The  name  of  membranous  dysmenorrhea  was 
bestowed  upon  the  condition  by  Oldham,  who  in  1849  contributed  an 
interesting  descriotion  of  the  disorder. 


212  MENSTRUATION  AND  ITS  DISORDERS 

There  was  much  discussion  in  former  years  as  to  the  actual  existence  of 
such  a  condition  as  membranous  dysmenorrhea.  For  example,  Hausman, 
in  an  exhaustive  consideration  of  the  subject  delivered  before  the  Obstetrical 
Society  of  Berlin,  arrived  at  the  following-  conclusions :  ( i )  A  decidual 
menstrual  disease  of  the  uterine  mucosa  as  a  "  morbus  sui  generis  "  does 
not  exist;  (2)  all  cases  reported  as  decidual  affections  are  to  be  considered 
as  miscarriages  in  the  first  weeks  of  pregnancy,  probably  caused  by  some 
morbid  condition  of  the  ovum;  (3)  the  coincidence  at  the  time  of  menstrua- 
tion is  incidental;  (4)  a  symptomatic  treatment  and  abstinence  from 
coitus  for  a  few  months  is  sufficient  to  cure  the  affection. 

A  considerable  number  of  cases  have  been  reported,  however,  in  which 
the  possibility  of  pregnancy  can  be  absolutely  excluded.  This  fact,  together 
with  the  recent  advances  in  the  study  of  the  menstrual  histology  of  the 
endometrium,  leaves  no  room  for  doubt  as  to  the  occurrence  of  membranous 
dysmenorrhea  as  a  definite  clinical  entity. 

Clinical  Characteristics. —  The  distinguishing  feature  of  this  form  of 
dysmenorrhea,  as  already  mentioned,  is  the  passage  by  the  patient  of  a 
greater  or  less  amount  of  membrane  with  the  menstrual  discharge.  The 
membrane  may  be  passed  on  the  first,  day  of  the  flow,  but  much  more  fre- 
quently comes  away  on  the  second  or  third,  and  occasionally  even  later. 
Before  this  happens,  the  patient  usually  suffers  with  severe  cramp-like  pains, 
usually  compared  in  their  intermittence  with  labor  pains.  After  the  mem- 
brane is  passed,  the  pain  almost  always  ceases.  It  is  stated  that  the  men- 
strual flow  also  becomes  much  more  profuse,  but  I  have  not  noted  this  in 
the  cases  which  I  have  observed.  Occasionally,  as  in  Ehrenfest's  case, 
membranes  are  passed  at  the  menstrual  periods  without  any  pain  whatso- 
ever. These  cases  are,  however,  certainly  not  the  rule,  and  when  they  do 
occur  the  designation  of  membranous  dysmenorrhea  is  of  course  a  misnomer. 

Other  than  the  occurrence  of  the  pain,  menstruation  in  most  cases  is 
quite  regular  and  normal.  Not  infrequently  there  may  be  some  pelvic 
lesion  which  causes  more  or  less  intermenstrual  pain  or  other  symp- 
toms, but  membranous  dysmenorrhea  is  frequently  observed  when  the 
patient  is  otherwise  in  good  health. 

Etiology. —  Up  to  a  few  years  ago  the  subject  of  the  etiology  of  mem- 
branous dysmenorrhea  was  very  obscure  indeed.  The  work  of  Hitschmann 
and  Adler,  however,  has  given  a  new  trend  to  investigation  along  this  line, 
and  has  added  substantially  to  our  knowledge  of  the  real  nature  of  this 
condition.  The  older  theories  were,  in  the  main,  quite  speculative  in  char- 
acter. Scanzoni  considered  the  affection  as  one  of  the  congestive  dysmen- 
orrheas, explaining  the  painful  expulsion  of  membrane  by  the  fact  that  the 
blood,  being  prevented  from  escaping  by  the  greatly  thickened  mucosa, 
gradually  loosens  the  latter  and  causes  its  expulsion.  Hegar  and  Eigen- 
brodt  designate  the  affection  as  "  dysmenorrhea  apoplectica,"  while  Gautier 
speaks  of  it  as  "  uterine  ichthyosis." 

Up  to  quite  recent  years  there  were  many  who  believed  that  membranous 


DYSMENORRHEA  213 

dysmenorrhea  is  always  the  result  of  an  inflammatory  process,  hence  the 
name  "  exfoliative  endometritis."  Aschheim,  after  the  examination  of 
seven  cases  of  menstrual  membrane  thrown  off  by  patients  observed  in  his 
clinic,  states  that  such  membranes  are  the  product  of  an  acute  exudative 
endometritis.  In  general,  he  says,  the  membrane  consists  of  necrotic  stroma, 
filled  with  leucocytes,  with  a  fibrinous  reticulum.  The  membrane  forms  in 
the  intermenstrual  period,  and  is  thrown  off  about  the  third  day  of  men- 
struation. Remains  of  the  uterine  mucosa  are  usually  to  be  found  in  the 
membrane,  which  Aschheim  thus  considers  practically  an  inflammatory 
exudate.  No  bacteria  were  found  in  the  membrane  by  Aschheim.  The 
causes  of  the  inflammation  he  describes  as  general  and  local.  General  con- 
ditions that  cause  exfoliation  are  anemia,  chlorosis,  scrofula,  tuberculosis 
and  syphilis.  Local  conditions  are  fibroma,  chronic  metritis,  ovarian  dis- 
eases, parametritis,  abortion  and  stenosis  of  the  canal  of  the  uterus. 

The  recent  work  of  Hitschmann  and  Adler  discredits  the  theory  of  the 
inflammatory  origin  of  membranous  dysmenorrhea.  These  investigators 
described  the  cycle  of  histological  changes  which  occur  in  the  endometrium 
in  connection  with  the  menstrual  cycle  (Chapter  IV),  and,  among  other 
things,  they  demonstrated  that  in  the  premenstrual  endometrium,  as  in 
young  decidua,  two  definite  layers  can  be  differentiated.  The  superficial  or 
compact  layer  Is,  on  section,  found  to  be  comparatively  poor  in  gland  lumina, 
and  to  contain  a  large  amount  of  stroma.  The  cells  of  the  latter,  it  will  be 
recalled,  often  exhibit  much  hypertrophy,  so  that  they  even  suggest  decidual 
cells  in  appearance.  The  deep  or  spongy  layer  is  much  richer  in  gland 
elements  and  contains  much  less  stroma  than  the  superficial  stratum. 

Hitschmann  and  Adler  believe  that  the  separation  of  a  menstrual  cast  in 
membranous  dysmenorrhea  represents  an  exaggeration  of  the  normal 
process.  In  other  words,  they  consider  that  it  is  normal  for  more  or  less 
breaking  down  of  the  uterine  mucosa  to  occur  at  each  menstrual  period,  and 
for  fragments  to  be  cast  off  with  the  menstrual  blood.  This  is  contrary  to 
the  opinion  which  has  been  held  by  many  able  investigators.  On  the  other 
hand,  many  of  the  older  writers,  and  some  modern  authors,  have  held  the 
opinion  which  finds  expression  in  the  work  of  Hitschmann  and  Adler.  The 
latter  believe  that  in  the  most  marked  cases  there  is  a  complete  separation 
of  the  superficial  from  the  compact  layer,  with  the  formation  of  a  complete 
uterine  cast.  When  the  process  is  less  complete,  larger  or  smaller  fragments 
may  be  extruded  from  the  uterus. 

Mechanism  of  Detachment  of  Membrane. —  Hitschmann  and  Adler 
believe  that  the  cause  of  the  separation  of  the  membranes  in  these  cases  lies 
in  the  occurrence  of  unusually  severe  uterine  contractions,  which  are  espe- 
cially likely  to  bring  about  this  effect  if  the  two  layers  of  the  endometrium 
are  sharply  differentiated  from  each  other.  According  to  their  theory,  the 
cause  of  the  exaggerated  uterine  contractions  in  these  cases  Is  to  be  sought 
in  an  obstruction  of  the  cervical  canal  by  a  clot  of  blood.  Against  this,  as 
Ehrenfest  points  out,  Is  the  fact  that  dilatation  of  the  cervix  yields  very 


214 


MENSTRUATION  AND  ITS  DISORDERS 


discouraging  results  in  the  treatment  of  membranous  dysmenorrhea.  There 
is  no  convincing  evidence  to  support  the  explanation  of  Hitschmann  and 
Adler,  which  must  therefore  be  looked  upon  as  a  mere  hypothesis. 

Another  view,  which,  however,  is  equally  hypothetical,  is  that  of  Ehren- 
fest,  who  suggests  that  the  thin  septa  between  the  glands  of  the  spongy  layer 
may,  under  certain  conditions,  be  extensively  destroyed.  The  factors  which 
he  mentions  as  possible  causes  of  such  destruction  are  interstitial  hemorrhage 
and  excessive  compression  from  secretions  retained  in  the  glands.  If  blood 
vessels  are  ruptured  by  the  destruction  of  the  interglandular  septa  a  sub- 
mucous hematoma  may  form  and  bring  about  detachment  of  the  membrane. 
The  idea  that  the  membrane  is  thus  dissected  away  by  submucous  hemor- 
rhage was  suggested  many  years  ago  by  Gottschalk  and  others. 


Fig.  34. —  Cast  of  Uterus  in  a  Case  op  MEMSRANorrs  Dysmenorrhea  (Dudley). 

Structure  of  Menstrual  Membranes. — Macroscopic  Appearance. — 
A  perfect  menstrual  cast  of  course  possesses  the  shape  of  the  uterine  cavity. 
It  presents  three  openings,  two  corresponding  to  the  uterine  ostia  of  the 
tubes,  and  one  corresponding  to  the  internal  os  (Fig.  34).  Its  internal 
surface  is  smooth,  while  externally  it  is  irregmlar  and  perhaps  quite  shaggy. 
Its  walls  are  usually  thin  and  often  translucent.  In  other  cases,  however, 
the  walls  are  much  thicker.  Usually  the  membrane  is  more  or  less  rolled 
up  when  it  is  discharged,  so  that  its  characteristic  shape  is  not  readily 
apparent.  By  floating  it  in  water,  however,  its  character  and  shape  are 
revealed.  Much  more  frequently  the  membrane  is  passed,  not  as  a  complete 
cast,  but  in  the  form  of  fragments  of  variable  size  and  shape.     Often  they 


DYSMENORRHEA  215 

are  rather  flake-like  in  appearance,  and  a  number  may  be  passed  at  one  time. 
Microscopic    Structure. —  From    the    viewpoint    of    the    microscopic 
structure,  two  varieties  of  menstrual  membranes  may  be  distinguished :    ( i ) 
the  fibrinous,  and  (2)  the  endometrial. 

( 1 )  Fibrinous  membranes.  These,  as  the  name  mdicates,  are  made  up 
essentially  of  fibrin  or  clotted  blood.  The  mechanism  of  uterine  casts  of 
this  type  is  easy  to  comprehend.  Under  certain  conditions,  as  yet  little 
understood,  menstrual  blood  coagulates  within  the  uterine  cavity,  and  the 
clot  may  be  extruded  as  a  mould  of  the  uterine  cavity.  Cases  of  this  type, 
to  my  mind,  are  not  to  be  classified  as  instances  of  membranous  dysmenor- 
rhea. In  a  certain  number,  however,  the  meshwork  of  fibrin  contains,  in 
addition  to  leukocytes  and  red  corpuscles,  a  considerable  number  of  stromal 
cells.  Usually  the  latter  are  large  and  swollen,  and  perhaps  suggestive  of 
decidual  cells.  When  these  tissue  elements  are  present  in  considerable 
amount,  the  designation  of  membranous  dysmenorrhea  would  seem  to  be 
justified. 

(2)  Endometrial  membranes.  Bell  divides  membranes  of  this  type  into 
two  varieties,  the  thick  and  the  thin.  These  terms,  however,  have  reference 
to  the  thickness  of  the  wall  of  the  cast,  and  there  would  seem  tO'  be  no 
especial  advantage  in  making  the  distinction.  The  membranes  which  I  have 
had  the  opportunity  of  examining  microscopically  have  rarely  been  rich  in 
glandular  elements.  When  glands  are  observed  they  are  usually  rather 
wide  and  only  moderately  convoluted,  if  at  all.  In  other  words,  they  sug- 
gest, as  they  obviously  are,  the  gland  channels  of  the  superficial  layer  of  the 
endometrium. 

The  most  conspicuous  histological  element  in  all  these  cases  is  the  stroma. 
I  agree  with  Bell  as  to  the  incorrectness  of  Cuthbert  Lockyer's  statement 
that  "  the  cells  in  menstrual  endometrial  casts  are  small,  shrunken,  and 
branching;  the  stroma  is  formed  of  a  slender  adenoid  reticulum."  As  Bell 
remarks,  this  description  applies  to  the  stroma  in  the  postmenstrual  or  rest- 
ing stages  of  the  menstrual  cycle.  On  the  contrary,  the  stromal  cells  found 
in  the  endometrial  cast  are  characteristically  large  and  overgrown,  this  being 
accentuated  by  the  edema  which  is  almost  invariably  associated,  and  which 
gives  the  tissue  a  very  loose  texture  (Fig  35). 

The  decidua-like  appearance  ("  decidua-ahnlichkeit ")  sometimes  ob- 
served in  the  normal  endometrium  just  before  menstruation  is  always 
exaggerated  in  the  menstrual  cast,  although  there  are  great  differences  in 
the  degree  of  this  change.  In  the  most  extreme  cases  the  mimicry  of 
genuine  decidual  cells  is  very  striking,  so  that  one  finds  it  difficult  to  con- 
vince oneself  that  pregnancy  has  not  been  present.  Bell  lays  stress  on  the 
"  ground  glass  appearance  "  of  the  stroma  caused  by  the  marked  effusion  of 
blood  serum  among  the  cells.  This,  he  says  is  absent  in  the  decidua  of 
pregnancy. 

Diagnosis. —  The  conditions  from  which  membranous  dysmenorrhea 
must  be  distinguished  are  those  which  are  likewise  associated  with  the  pas- 


216 


MENSTRUATION  AND  ITS  DISORDERS 


sage  of  membrane;  per  vaginam.  By  far  the  most  important  of  these  is 
early  abortion.  The  differential  diagnosis  between  membranous  dysmenor- 
rhea and  early  abortion  is  frequently  of  great  practical  importance,  and  it  is 
often  exceedingly  diffictdt,  even  with  the  aid  of  the  microscope.  As  stated 
above,  it  was  formerly  believed  by  many  that  all  cases  of  supposed  mem- 
branous dysmenorrhea  are  really  instances  of  early  abortion.  While  this 
can  no  longer  be  accepted  as  true,  it  cannot  be  doubted  that  many  cases  are 
diagnosed  as  membranous  dysmenorrhea  which  are  probably  early  abortion, 
and  vice  versa. 


^  ****** *  .«*-.    *  *>  : 


■t « •♦•♦J'  :  ty  •!  .-im.  •  ♦*:  3?  ^-.v  *  ^ 


|i^< 


Pig.  35.- 


■  Structure  of  Uterine  Cast  of  the  Decidual  Type,  Associated  With 
Membranous  Dysmenorrhea. 


The  patient  passed  large  flakes  of  membrane  of  this  structure  at  each  menstrual  period 
(personal  case). 

Occasionally  the  history  of  the  case  is  such  as  to  make  it  reasonably  or 
perhaps  absolutely  certain  that  pregnancy  could  not  have  existed.  It  is 
scarcely  necessary  to  emphasize  the  caution  which  must  be  exercised  in 
arriving  at  this  conclusion.  A  case  reported  by  Fieux  illustrates  this  point. 
His  patient  was  a  woman  who  had  always  had  extreme  pain  at  the  menstrual 
periods,  at  which  time  she  had  as  a  rule  passed  distinct  membranous  shreds. 
After  a  period  of  amenorrhea  lasting  two  months,  she  had  a  painful  but 
scanty  menstruation,  and  one  month  later  another  painful  period  with  the 
expulsion  of  membrane.  Careful  examination  showed  that  the  membrane 
contained  a  very  small  amniotic  sac  with  a  broken  down  embryo  under  ten 


DYSMENORRHEA  217 

millimetres  in  length.  The  deciclua  had  evidently  been  retained  long  after 
the  death  of  the  fetus. 

From  a  microscopic  standpoint,  it  is  sometimes  very  easy  to  determine 
the  exact  nature  of  membranes  passed  at  the  menstrual  period ;  at  other 
times  it  is  impossible.  The  presence  of  chorionic  villi  of  course  fixes  the 
diagnosis  of  pregnancy.  When  these  are  absent,  the  diagnosis  is  not  always 
easy.  If  the  membrane  consists  of  fibrin,  with  small,  i.  e.,  non-hypertrophic, 
stromal  cells,  pregnancy  may  be  excluded  with  reasonable  certainty.  When, 
how'ever,  the  membrane  is  made  up  of  large  decidua-like  cells,  as  it  so  fre- 
quently is,  the  distinction  between  a  menstrual  membrane  and  early  abortion 
may  be  exceedingly  difficult.  In  these  cases  the  history  of  the  patient  should 
be  investigated  with  the  greatest  detail.  Even  then,  only  a  presumptive 
diagnosis  can  be  made  in  a  certain  proportion  of  the  cases. 

Vaginal  membranes  are  occasionally  passed  during  menstruation,  and  may 
be  mistaken  for  those  coming  from  the  uterine  body.  In  the  majority  of 
such  cases  the  history  will  show  that  the  patient  has  been  using  an  irritant 
douche,  or  has  perhaps  been  given  treatment  by  a  gynecologist.  Silver 
nitrate  especially  is  apt  to  cause  the  desquamation  of  thin  membranous  shreds 
from  the  vagina  or  from  the  pars  vaginalis.  If  there  is  any  doubt  about  the 
source  of  the  membrane,  the  presence  or  absence  of  squamous  epithelium  on 
microscopic  examination  will  decide  the  matter. 

In  certain  other  conditions,  as  in  adenocarcinoma  of  the  fundus,  or  with 
a  sloughing  submucous  myoma,  it  is  possible  that  the  patient  may  in  rare 
cases  pass  shreds  of  tissue  with  the  menses.  The  other  signs  and  symptoms 
of  such  conditions  are  usually  so  definite  that  the  question  of  differentiating 
them  from  membranous  dysmenorrhea  almost  never  arises. 

Prognosis. —  The  prognosis  of  membranous  dysmenorrhea  is  as  a 
rule  distinctly  unfavorable.  In  some  cases  there  are  periods  of  remission 
from  both  the  pain  and  the  passage  of  membranes,  but  relapses  are  the  rule. 

Treatment, —  On  the  whole,  the  treatment  of  membranous  dysmen- 
orrhea cannot  be  said  to  offer  any  great  prospect  of  success.  Aside  from  the 
mere  relief  of  pain,  the  measures  which  have  been  recommended  are  quite 
empirical.  Two  plans  of  management  have  been  practiced  in  the  past. 
The  first,  on  the  assumption  that  the  condition  is  due  to  some  local  inflam- 
matory process  in  the  uterus,  consists  in  intra-uterine  applications  of  such 
substances  as  carbolic  acid,  iodin,  or  even  sulphuric  and  nitric  acids.  In 
addition  to  this  local  medication,  curettage  has  often  been  resorted  to,  some- 
times repeatedly. 

The  other  plan  of  management  embodies  the  principle  of  "  masterly  inac- 
tivity," so  far  as  local  treatment  of  the  uterus  is  concerned.  According  to 
this  plan,  only  general  treatment  is  carried  out,  by  means  of  such  tonics  as 
iron  and  arsenic.  A  neurotic  tendency  is  said  to  be  present  in  some  cases, 
and  for  this  various  nerve  sedatives,  such  as  the  bromids,  are  administered. 

From  a  negative  point  of  view,  at  least,  the  latter  method  of  treatment 
would  seem  to  commend  itself.     Certainly  there  is  no  real  evidence  that 


218  MENSTRUATION  AND  ITS  DISORDERS 

local  antiseptic  or  escharotic  treatment  of  the  uterine  mucosa  has  evef  been 
of  any  service.  If  our  present  day  conception  of  the  nature  of  membranous 
dysmenorrhea  be  correct,  such  drastic  treatment  is  irrational,  to  say  the  least. 
For  the  symptomatic  treatment  of  the  pain  associated  with  this  condition 
the  various  measures  which  have  already  been  recommended  for  the  relief  of 
dysmenorrhea  are  of  service. 

NASAL  DYSMENORRHEA 

General  Considerations. —  A  form  of  dysmenorrhea  of  rather  special 
etiology  and  also,  I  may  say,  of  rather  special  interest,  is  that  to  which  the 
rhinologist  Fliess  called  attention  in  1893,  ^^"^^  o^^  which  he  published  an 
extensive  monograph  in  1897.  I  refer  to  the  so-called  "  nasal  dysmenor- 
rhea,'' which  h^s,  since  its  description  by  Fliess,  been  the  subject  of  sporadic 
reports  by  various  authors.  It  seems  to  me,  however,  that  it  has  not  been 
investigated  with  the  thoroughness  or  finality  to  which  its  interest  and 
importance  would  seem  to  entitle  it.  It  has  long  been  known  that  there 
is  a  biological  and  perhaps  also  a  physiological  connection  between  the  repro- 
ductive organs  and  the  nose.  Siefert,  writing  in  1912,  gives  reference  to  as 
many  as  296  articles  dealing  with  this  relationship  which  are  to  be  found  in 
the  literature. 

The  "  Genital  Spots  "  in  the  Nose. —  From  an  anatomic  standpoint 
it  is  of  interest  to  note  that  erectile  tissue  is  found  in  the  nose,  as  in  the 
genital  tract.  In  the  nose  the  erectile  tissue  is  found  especially  at  the 
anterior  end  of  the  inferior  turbinated  bone  and  in  the  small  circumscribed 
area  known  as  the  tuberculum  of  the  nose.  These  are  the  two  areas  which 
Fliess  designated  as  the  genitalstellen  or  genital  spots.  During  menstrua- 
tion these  spots,  according  to  Fliess,  are  invariably  swollen  and  congested, 
so  that  they  bleed  on  the  slightest  touch.  In  addition,  they  are  said  to  be 
markedly  hypersensitive  during  the  menstrual  flow.  All  of  these  character- 
istics are  said  to  disappear  as  soon  as  menstruation  ceases.  The  theory  that 
there  is  some  intimate  relationship  between  these  spots  and  the  functions  ol 
the  generative  organs  is  further  strengthened  by  the  frequent  occurrence  of 
nasal  bleeding  as  a  vicarious  phenomenon  at  the  menstrual  epochs. 

Theories  of  Nature  of  Relation  Between  Generative  Organs  and 
Nose. —  No  very  satisfactory  explanation  has  been  presented  for  the 
evident  relation  which  exists  between  the  olfactory  and  sexual  apparatus. 
It  has  been  suggested  that  the  physiological  connection  between  the  two  is 
brought  about  through  the  agency  of  the  sympathetic  nervous  system. 
Siegmund,  on  the  other  hand,  attempted  to  explain  it  by  a  rather  complicated 
theory  based  upon  the  so-called  hypothesis  of  Head.  In  view,  however,  of 
the  great  advances  which  recent  years  have  brought  in  our  knowledge  of 
the  internal  secretions,  and  knowing  as  we  now  do  that  these  internal  secre- 
tions or  hormones  are  capable  of  exerting  a  selective  action  upon  organs  or 
tissues  far  removed  from  those  which  produce  the  hormones,  it  seems  much 
more  logical  to  look  to  the  hormone  theory  for  an  explanation  of  the  many 


DYSMENORRHEA  219 

interesting  evidences  of  a  functional  relationship  between  the  nose  and  the 
sexual  organs. 

The  Cocain  Test  of  Nasal  Dysmenorrhea. —  Fliess  distinguishes  two 
clinical  types  of  menstrual  pain,  one  in  which  the  pain  ceases  with  the 
appearance  of  the  menses,  the  other  in  which  the  pain  continues  after  the 
menses  have  commenced.  The  first,  he  believes,  is  always  due  to  cervical 
stenosis.  The  second  type  includes  many  patients  in  whom  cocainization 
of  the  genital  spots  causes  cessation  of  the  menstrual  pain.  These  are  the 
cases  which  Fliess  designates  as  "  dysmenorrhea  nasalis."  The  condition 
of  the  pelvic  organs  he  says  is  without  importance,  being  normal  in  some 
and  pathological  in  others. 

Permanent  Cure  of  Nasal  Dysmenorrhea. —  If,  in  cases  of  this  type, 
the  cocain  test  proves  positive  and  the  patient  obtains  temporary  benefit,  it 
is  then  often  possible  to  give  her  permanent  relief  by  cauterization  of  the 
genital  areas  by  means  of  the  galvanocautery,  electrolysis,  or  trichloracetic 
acid.  In  addition,  any  pathological  condition  existing  in  the  nasal  chambers 
must  be  remedied.  More  than  loo  cases  in  which  permanent  cure  of 
dysmenorrhea  followed  this  method  of  treatment  are  offered  by  Fliess  in 
substantiation  of  the  views  above  expressed. 

A  number  of  other  observers  have  published  results  in  confirmation  of  the 
claims  of  Fliess.  Among  these  is  SchifT,  whose  work  was  done  in  the 
clinic  of  Chrobak,  at  Vienna.  Not  only  does  Schifif  endorse  the  findings  of 
Fliess,  but  he  goes  so  far  as  to  assert  that  the  application  of  cocain  to  the 
anterior  end  of  the  inferior  turbinate  causes  a  disappearance  of  pain  in  the 
hypochondrium,  while  a  similar  application  to  the  tuberculum  of  the  septum 
controls  the  backache.  On  the  other  hand,  irritation  of  these  spots  with  the 
end  of  a  probe  produces  the  corresponding  pain.  In  other  words,  the 
hypochondriac  pain  seems  in  some  way  to  be  related  with  the  anterior  end 
of  the  inferior,  and  backache  with  the  tuberculum.  I  am  not  aware  of  any 
observations  in  confirmation  of  this  hypothesis,  which  moreover  lacks  the 
ring  of  plausibility,  in  view  of  the  different  mechanism  of  these  various 
types  of  pain  in  different  cases.  Schifif,  I  may  add,  found  that  72  per  cent 
of  all  cases  of  dysmenorrhea  could  be  treated  by  the  nasal  method. 

A  similar  experience  is  reported  by  Linder  from  Amann's  clinic  at 
Munich.  About  thirty  cases  were  treated  by  Fliess'  method.  Almost  every 
patient  was  relieved.  Incidently,  he  remarks  that  several  patients  were  com- 
pletely relieved  when  water  was  substituted  for  the  cocain  without  their 
knowledge,  suggesting  the  importance  of  the  psychic  factor  in  the  treatment. 
In  others  only  cocain  afiforded  relief.  He  believes  that  suggestion  plays  an 
important  part  in  the  cure  of  such  cases,  but  does  not  believe  that  it  explains 
all  the  good  results. 

The  recent  publications  of  Mayer  and  Brettauer  have  brought  this  subject 
to  the  attention  of  the  profession  of  this  country.  Brettauer  in  19 13  re- 
ported 66  cases  treated  by  the  nasal  method.  Of  these,  33  were  immediately 
benefited,  by  which  Brettauer  means  that  the  first  menstruation  after  the 


220  MENSTRUATION  AND  ITS  DISORDERS 

treatment  was  painless;  17  were  immediately  improved,  the  degree  of  pain 
being  much  less ;  15  showed  no  relief  whatever.  Taking  into  consideration 
the  cases  which  he  was  able  to  follow  up,  he  finds  that  in  more  than  one  half 
of  those  treated  there  was  immediate  relief,  and  that  relief  was  permanent 
in  about  one  third.     He  is  therefore  convinced  of  the  value  of  the  treatment. 

Equally  enthusiastic  is  the  opinion  of  Mayer,  who  has  recently  reported 
a  series  of  93  cases,  which  number,  I  believe,  includes  those  of  Brettauer. 
The  majority  of  Mayer's  patients  are  described  as  having  had  premenstrual 
headaches  and  nausea  from  one  to  two  weeks  before  the  period,  to  be 
followed  by  abdominal  pains  during  the  first  two  days,  often  of  so  severe 
a  nature  as  to  compel  the  patient  to  go  to  bed,  losing  at  least  two  days  each 
month. 

As  to  the  effects  of  the  treatment  he  says  "  When  we  recall  the  extreme 
pallor  of  one  of  these  sufferers  as  she  slowly  dragged  her  way  to  the  office 
for  treatment,  her  firmly  compressed  lips  and  utter  weariness,  and  then 
within  a  few  minutes  after  a  local-  application  to  her  nose  how  her  color 
came  back,  her  breathing  was  free  and  she  went  about  her  duties  instead  of 
to  bed  as  usual,  we  feel  that  we  have  earned  her  gratitude."  Of  his  93 
patients,  no  report  was  available  from  12,  leaving  81  for  analysis.  Of  these 
48  were  cured,  14  were  improved,  and  19  were  unrelieved.  He  concludes 
that  permanent  relief  is  obtainable  by  intranasal  treatment  in  from  50  to  75 
per  cent  of  the  cases. 

Need  of  Caution  in  Estimating  Results  of  Treatment. —  Kuttner 
agrees  as  to  the  frequency  with  which  dysmenorrhea  disappears  after  cocain- 
ization  of  the  genital  spots.  He  finds,  however,  that  applications  of  menthol 
and  other  substances  will  produce  the  same  effect.  He  believes  that  the 
good  results  of  the  nasal  treatment  of  dysmenorrhea  are  due  in  a  large 
measure  to  the  psychic  influence  on  the  patient,  the  general  effect  of  the 
cocain  after  absorption  into  the  circulation,  and  the  improvement  in  the 
patient's  general  condition  which  comes  when  the  nasal  treatment,  as  often 
happens,  brings  about  cure  of  a  nasal  stenosis. 

To  illustrate  the  risk  of  jumping  at  conclusions  as  to  the  success  of  the 
treatment,  he  mentions  the  case  of  a  patient  who  had  for  five  years  been 
treated  regularly  for  four  or  five  days  each  month  in  his  clinic.  Without 
the  treatment  the  pain  would  be  unbearable.  This  case,  he  says,  would 
naturally  be  looked  upon  as  a  good  demonstration  of  the  intranasal  treat- 
ment, were  it  not  for  the  fact  that  on  Sundays  and  holidays,  when  the  clinic 
was  closed,  the  patient  was  in  the  habit  of  taking  a  few  drops  of  cocain 
solution  by  mouth,  with  the  same  relief  as  when  it  was  applied  in  the  nose. 

Method  of  Treatment. —  It  is  advised  by  Mayer  and  Brettauer  that 
the  local  treatment  in  the  nose  be  given  four  times,  at  intervals  between  the 
menstrual  periods.  As  already  stated,  the  application  of  a  twenty  per  cent 
cocain  solution  is  used  for  the  "  cocain  test,"  to  distinguish  cases  of  nasal 
dysmenorrhea  from  others.     If  the  test  be  positive,  more  permanent  relief 


DYSMENORRHEA  221 

will  be  given  by  treating  the  genital  spots  at  intervals,  as  above  mentioned, 
with  trichloracetic  acid. 

The  areas  to  be  treated  are  first  anesthetized  by  applying  for  a  few  min- 
utes pledgets  of  cotton  saturated  with  a  20  per  cent  solution  of  cocain. 
When  sensation  has  disappeared,  a  crystal  of  trichloracetic  acid  is  applied 
on  the  end  of  a  probe  to  the  tuberculum  septi,  and  another  in  the  same  way 
to  the  other  genital  spot  at  the  anterior  end  of  the  inferior  turbinate.  The 
procedure  is  carried  out  in  both  nasal  cavities.  The  application  is  followed 
by  the  formation  of  a  slough,  which  disappears  in  about  five  days,  when  the 
treatment  may  be  repeated,  thus  allowing  of  about  four  treatments  between 
menstrual  periods. 

If  the  ensuing  menstrual  flow  is  unaccompanied  by  pain,  no  further  treat- 
ment may  be  necessary.  If,  on  the  other  hand,  dysmenorrhea  still  continues, 
the  same  plan  of  treatment  must  be  repeated  a  second  time.  The  galvano- 
cautery  has  been  used  in  some  cases  instead  of  the  trichloracetic  acid,  but 
its  employment  is  accompanied  by  some  danger  of  synechia. 

XX 

LITERATURE 

Handler.     Therapeutic  Differential   Diagnosis  of   Constitutional   Dysmenor- 
rhea.    Arch,  of  Diag.,  1913,  6.  5. 
Bell.     Pathology    of    Uterine    Casts    Passed    During    Menstruation.     Surg., 

Gyn.,  and  Obst,  1913,  16,  651. 
Beyea.     Primary    Dysmenorrhea,    its    Etiology    and    Treatment    by    Forcible 

Dilatation  of  the  Cervical  Canal  and  Applications  of  the  Wylie  Drain. 

Univ.  Penn.  M.  Bull.,  1910-11,  23,  137. 
Blau.     Wesen  und  Behandlung  der  Dysmenorrhoe.     Med.  Klin.,  1913,  9,  653. 
Block.     Some  Observations  on  the  Treatment  of  Dysmenorrhea.     Amer.  J. 

Obst,  1915,  72,  945. 
Boldt.     Discission  and  Adjustment  of  Intra-uterine  Stem  Versus  Dilatation  to 

Overcome  Stenosis  of  Cervical  Canal.     Jour.  A.  M.  A.,  1916,  66,  1000. 
Brettauer.     Dysmenorrhea  Relieved  by  Nasal  Treatment.     Amer.  J.  Obst., 

1911,64,214. 
• Further  Report  of  Cases  of  Dysmenorrhea  Relieved  by  Nasal  Treat- 
ment.    Surg.,  Gyn.,  and  Obst,  1913,  17,  381. 
Carstens.     Amenorrhea,  Dysmenorrhea,  Sterility  and  Endometritis  as  a  Rule 

Relieved  by  Silver  Stem  Pessary,  etc.     Medicine  and  Surgery,   191 7, 

I,  617. 
Cook.     Membranous  Dysmenorrhea.     Am.  J.  Obst,  1898,  37,  786. 
CoTTE.     Tuberculose    inflammatoire ;    dysmenorrhee    d'origine    tuberculeuse. 

Gaz.  d.  Hop.,  Paris,  1909,  82,  1447. 
Dalche      Dysmenorrhee  membraneuse,   etc.     Gaz.   d.   hop..   Par.,    1908,  81, 

171. 
Doderlein.     Dysmenorrhea  Essentialis.     Surg.,  Gyn.  and  Obst.,  1914,  19,  165, 
Drenkhahn.     Die  Behandlung  der  Dysmenorrhoe.     Zentralb.  f.  Gyn.,  1910, 

34,  1531- 


222  MENSTRUATION  AND  ITS  DISORDERS 

Ehrenfest.  Endometritis  Exfoliativa;  Dysmenorrhea  Membranacea.  Tr. 
Amer.  Gyn.  Soc,  1908,  2,3,  423. 

Falta.  Relation  between  Nose  and  Female  Generative  Organs.  Ungar.  Med, 
Presse,  1905,  10,  543. 

Fliess.  Beziehungen  zwischen  Nase  und  Weiblichen  Geschlechtsorganen. 
Leipsic,  1897. 

Frankel  and  Scroggs.  Case  of  Decidual  Expulsion  Occurring  at  Each  Men- 
strual Period.     Am.  J.  Obst.,  1909,  60,  438. 

VON  Franque.  Endometritis  und  Dysmenorrhoe.  Zentralb.  f.  Gyn.,  1898,  22, 
306. 

Gibbons.     A  Lecture  on  Dysmenorrhea.     Brit.  M.  J.,  1910,  i,  676. 

Grafenburg.     Dysmenorrhoe    and    Tuberkulose.      Miinch.    Med.    Wchnsch., 

1910,57.515- 
Hagemann.     Correlation  between  Olfactory  and  Genital  Functions  in  Human 

Female.     Med.  Press  and  Circ,  1916,  loi,  195. 
Hager  and  Becht.     Action  of  Viburnum  Prunifolium.     J.  Pharmacol,  and 

Exp.  Ther.,  1919,  13,  61. 
Hammond.     Medical  Treatment  of  Dysmenorrhea.     Amer.  Med.,  1903,  6,  366. 
Herman.     An  Address  on  Dysmenorrhea.     Brit.  M.  J.,  1909,  i,  937. 
■ Causes  and  Treatment  of  Dysmenorrhea.     Surg.,  Gyn.  and  Obst.,  1910, 

II,  1210. 
Hitschmann  und  Adler.     Die  Dysmenorrhoea  Membranacea  (Endometritis 

Exfoliativa).     Monats.  f.  Geb.  u.  Gyn;,  1908,  27,  200. 
Holden.     Dilatation  and  Curetment  for  Dysmenorrhea  :  a  Report  of  95  Cases. 

Amer.  Med.,  1905,  10,  yyS. 
Hollos  und  Eisenstein.     Tuberculose  und  Menstruation.     Zentralb.  f.  Gyn., 

1908,  32,  1441. 
Die   Tuberkulose   Atiologie   der   Dysmenorrhoe,   etc.     Gyn.    Rundsch., 

1907,  I,  901. 
Kelly.     Medical  Gynecology.     New  York,  1908. 
Kermauner,     Ueber  Atiologie  und  Therapie  der  Dysmenorrhoe.     Monats,  f. 

Geb.  u.  Gyn.,  1907,  26,  645. 
Kuttner.     Die  Nasale  Dysmenorrhoe.     Deutsch.  Med.  Wchnsch.,  1908,  34, 

1050. 
Lepage.     Du  diagnostic  de  la  dysmenorrhea  membraneuse  et  de  la  grossesse 

extra-uterine.     Compt.  Rend.  Soc.  d'Obst,  de  Gynec.  et  de  Paediat.  de 

Paris,   1910,   12,  79. 
Litzenberg.     Use  of  Benzyl  Benzoate  in  Dysmenorrhea.     Jour.  A.  M.  A., 

1919,  73,  601. 
Lockard.     Nasal  Dysmenorrhea.     Colorado  Med.,  1915,  12,  no. 
Mackenzie.     Irritation  of  Sexual  Apparatus  as  an  Etiological  Factor  in  the 

Production  of  Nasal  Disease.     Am.  J.  Med.  Sci.,  1884,  87,  360. 
Macnaughton.     Pain    Associated    with    Disorders    of    the    Female    Genital 

Organs.     Proc.   Roy.   Soc.   Med.,   Lond.,    1909-10,   3,   Obst.   and   Gyn. 

Sect.,  i-io. 
Matiies     Ueber  Atiologie  und  Therapie  der  Dysmenorrhoe.     Monats  f.  Geb. 

u.  Gyn.,  1908,  28,  73. 
Mayer,     The  Intranasal  Treatment  of  Dysmenorrhea.     Jotfr.  A.  M.  A.,  1914, 

62,  6, 


.    DYSMENORRHEA  223 

Mayer.     Infantilismus.     Gyn.  Rundsch.,  1913,  7,  505. 

MoRiCKE.     Ueber  Menstruation  und  Dysmenorrhoe.     Halle,  1898. 

Morse.     Report  of  Four  Cases  of  Membranous  Dysmenorrhea.     Bull.  Johns 

Hopkins  Hosp.,  1907,  18,  40. 
NoRRis  AND  Barnard.     Dysmenorrhea  in  Alukiparous  Women  without  Gross 

Pathological  Lesions.    Am.  J.  Obst,  1910,  61,  753. 
Novak,  E.     The  Atropin  Treatment  of  Dysmenorrhea.     Jour.  A.  M.  A.,  191 5, 

64,  120. 

Infantilism  and   other   Hypoplastic   Conditions   of  the   Uterus.     Jour. 

A.  M.  A.,  1918,  71,  iioi. 

Novak,  J.    Zur  Atropinbehandlung  der  Dysmenorrhoe.     Wien.  Klin.  Wchnsch., 

1913,  26,  2068. 

O'Reilly.     Observations   on   Intranasal   Treatment   of   Dysmenorrhea.     Am. 

J.  Obst,  1915,  'J2,  634. 
Pechner,     Intranasal  Treatment  of  Dysmenorrhea.     Med.  Rev.  of  Rev.,  1916, 

22,  684. 
PiLCHER,,  BuRMAN  AND  Delzell.     Action  of  Various  Female  Remedies,  etc. 

Arch.  Int.  Med.,  1916,  18,  557. 
Poland.     Zur    Behandlung    der    Dysmenorrhoe    von    den    Brustdriisen,    etc. 

Miinch.  Med.  Wchnsch.,  1907,  54,  2335. 
Pozzi.     Surgical  Treatment  of  a  Most  Frequent  Cause  of  Dysmenorrhea  and 

Sterility  in  Women.     Surg.,  Gyn.  and  Obst.,  1909,  9,  m. 
ScHiFF.     Ueber  die  Beziehung  zwischen  Nase  und  Weiblichen  Organen.  Wien. 

Klin.  Wchnsch.,   1901,   14,  57. 
ScHULTz.     Ein   Beitrag  zur  Atiologie   und   Pathogenese   der  Dysmenorrhoe. 

Monats.  f.  Geb.  u.  Gyn.,  1903,  18,  854. 
Seifert.     Kritische  Studie  zur  Lehre  von  Zusammenhang  zwischen  Nase  und 

Geschlechtsorganen.     Zeitschr.    f.    Laryng.    Rhinol.    u.    ihre   Grenzgeb., 

1912,  5,  431. 
SiEGMUND.     Heads  Zonen  als   Mittel   zur   Erkennung  der   Nasalen   Reflex- 

neurose.     ]\Ied.  Klin.,   1907,  3,  1488. 
SiPPEL.     Ueber  Dysmenorrhoe.      Deutsch.  Med.  Wchnsch.,  1910,  36,  1785. 
Stolper.     tjber  Dysmenorrhoe.     Wien.  Med.  Wchnsch.,   1904,  54,  951. 

Zur   Atropinbehandlung    der    Dysmenorrhoe.     Wien   Klin.    Wchnsch., 

1914,  27,  46.  _ 

Tobler.     Ueber  Primare  und  Sekundare  Dysmenorrhoe.     Monats.  f .  Geb.  u. 

Gyn.,  1907,  26,  801. 
Veit.     Ueber  Dysmenorrhoe.    Miinch.  Med.  Wchnsch.,  1908,  55,  2434. 
ZiCKGRAF.     Zusammenhang  zwischen  Dysmenorrhoe  und  Tuberculose.    Ztschr. 

f.  Tuberk.,  1910,  16,  57. 


CHAPTER  XXI 
INTERMENSTRUAL  PAIN 

Definition. —  In  1872  Sir  William  O.  Priestly  described  the  condition 
to  which  he  gave  the  name  of  intermenstrual  pain.  The  special  character- 
istic of  the  disorder  is  the  regular  recurrence  of  pain  at  some  definite  period 
in  the  intermenstrual  cycle,  usually  about  midway  between  two  menstrual 
periods.  By  the  Germans  the  condition  is  spoken  of  as  "  mittelschmerz." 
As  Kelly  points  out,  however,  this  term  is  not  a  very  accurate  one,  inasmuch 
as  the  pain  does  not  always  occur  at  the  middle  of  the  intermenstrual  period. 

Frequency. —  The  total  number  of  cases  reported  in  the  literature  is 
not  very  large,  but  all  those  who  have  written  on  the  subject  insist  that  the 
condition  is  by  no  means  as  rare  as  is  generally  believed.  According  tO' 
Rosner,  the  condition  was  encountered  12  times  among  2350  gynecological 
patients.  Theilhaber  also  emphasizes  the  fact  that  careful  inquiry  into  the 
history  will  place  in  this  category  many  cases  which  would  otherwise  pass 
unrecognized.  He  states  that  by  such  intensive  search  he  came  upon  12 
cases  in  one  year  of  his  polyclinic  practice.  In  spite  of  these  observations, 
my  own  feeling  is  that  the  disorder  must  be  looked  upon  as  relatively  un- 
common. It  must  be  borne  in  mind  that  the  diagnosis  of  intermenstrual 
pain  is  not  justified  unless  the  pain  recurs  regularly  at  fixed  intervals  for  at 
least  a  number  of  months.  Either  the  patient  must  be  observed  over  a  long 
period  of  time,  or  else  her  history  on  this  point  must  be  unimpeachable. 
Although  I  have  long  been  interested  in  the  study  of  menstrual  disorders, 
I  have  encountered  only  a  very  small  number  of  definite  cases  of  intermen- 
strual pain. 

Time  of  Occurrence  of  Attacks. —  In  the  great  majority  of  cases,  the 
pain  occurs  at  or  near  the  middle  of  the  intermenstrual  epoch,  extending 
over  into  the  second  half  of  the  latter.  Unfortunately,  in  many  of  the 
reported  cases,  the  exact  date  of  occurrence  of  the  pain  with  reference  to 
the  menstrual  periods  is  not  given.  Often,  however,  instead  of -coming 
exactly  midway  between  periods,  the  attacks  will  occur  either  earlier  or 
later  in  the  cycle.  The  essential  feature  is  its  periodicity,  which  is  often  so 
well  marked  that,  to  quote  Kelly,  "  the  date  oi  the  approaching  period  can 
be  foretold  from  the  day  upon  which  the  intermenstrual  pain  appeared." 
To  illustrate  this,  Kelly  gives  the  following  record  of  a  typical  case  of  his 
own. 

224 


INTERMENSTRUAL  PAIN  225 

Menstruation December     i 

Intermenstrual  pain "  lo     Interval     9  days 

Menstruation "  19  "  9  *' 

Intermenstrual  pain "  30  "  11  " 

Menstruation January  10  "  11  " 

Intermenstrual  pain "  21  "  11  " 

Menstruation February  i  "  11  " 

Intermenstrual  pain "  17  "  16  " 

Menstruation March  5  "  16  " 

It  is  interesting,  as  well  as  significant,  to  note  that  during  periods  of 
amenorrhea,  as  during  pregnancy  or  lactation,  there  is  a  cessation  of  the 
attacks  of  intermenstrual  pain. 

Character  of  the  Pain. —  Many  adjectives  have  been  employed  in  the 
description  of  the  character  of  intermenstrual  pain  by  those  who  have 
reported  cases.  It  is  variously  described  as  "  sharp,"  "  paroxysmal," 
"  dull,"  "  aching,"  "  neuralgic  like,"  etc.  In  other  words,  no  especial  type 
of  pain  would  seem  to  be  characteristic  of  this  condition. 

Location  of  Pain. —  As  a  rule  the  pain  is  referred  chiefly  to  one  or 
other  of  the  iliac  fossae  —  sometimes  both.  In  severe  cases  the  pain  is  apt 
to  become  general  over  the  entire  lower  abdomen,  and  is  often  associated 
with  backache.     Not  infrequently  it  radiates  down  one  or  both  legs. 

Duration  of  Pain. —  In  mild  cases  the  pain  lasts  for  only  a  few  hours, 
but  in  others,  the  duration  may  be  several  days,  or  even  up  to  the  onset  of 
the  next  menstrual  period.  Most  frequently  the  pain  is  somewhat  intermit- 
tent, periods  of  relief  interrupting  its  severity. 

Associated  Vaginal  Discharge. —  In  a  large  number  of  the  reported 
cases  —  about  one  half  —  intermenstrual  pain  is  associated  with  a  vaginal 
discharge.  As  a  rule  this  is  described  as  being  mucoid  or  watery,  but  it  may 
be  thick  and  yellowish.  A  patient  whom  I  recently  saw  in  consultation  with 
Dr.  W.  J.  Schmitz,  of  Baltimore,  stated  that  each  attack  of  pain  was  accom- 
panied by  a  dark  brownish  discharge.  In  some  cases  the  discharge  occurs 
just  before  the  onset  of  the  pain,  while  in  perhaps  the  larger  number  its 
occurrence  and  subsidence  are  coincident  with  that  of  the  pain.  Exception- 
ally the  discharge  may  be  slightly  bloody,  although,  as  Kelly  cautions,  this 
may  be  due  to  such  associated  conditions  as  polypi,  endometritis,  etc. 

Age  of  the  Patients. —  As  a  rule  intermenstrual  pain  does  not  begin 
with  the  Inauguration  of  menstrual  life,  this  occurring  in  only  three  of 
forty-one  cases  collected  by  Kelly.  "  In  ten  cases  (including  the  three 
beginning  with  first  menstruation)  the  patient  was  under  twenty  when  the 
pain  began;  twenty-nine  of  the  remaining  cases  were  between  twenty  and 
thirty-five ;  while  two  were  over  thirty-five."  Heaney's  figures,  based  on 
sixty-six  collected  cases,  refer  to  the  age  of  the  patients  when  they  came 
under  observation  and  not  to  the  age  of  onset  of  the  trouble.  He  found  that 
42  patients  were  between  the  ages  of  25  and  35,  ten  over  35  years,  nine 
under  25  years,  while  in  5  the  age  was  not  stated.     These  figures  cor- 


226  MENSTRUATION  AND  ITS  DISORDERS 

roborate  those  of  Kelly,  and  confirm  the  latter's  statement  that  the  affection 
is  one  which  belongs  to  the  period  of  full  sexual  activity. 

Marital  and  Obstetrical  Histories  of  Patients. —  Both  Kelly  and 
Heaney  emphasize  the  frequency  with  which  sterility  is  observed  in  women 
subject  to  intermenstrual  pain.  Of  the  former's  64  cases,  "  32  had  never 
had  children  or  miscarriages  (eleven  of  them  being  married  and  21  single). 
Thirteen  had  had  neither  children  nor  miscarriages  for  as  much  as  5  years, 
and  in  most  cases  much  longer.  Fourteen  had  had  children,  or  miscarriages, 
or  both,  within  5  years ;  and  the  condition  of  5  as  regards  child  bearing 
was  not  stated."  Heany,  again,  found  that  among  35  who  were  married, 
II  had  never  been  pregnant,  while  11  had  been  pregnant  once,  7  twice,  4 
three  times,  i  four  times,  and  i  nine  times.  In  one  of  my  own  cases,  the 
trouble  dated  definitely  from  a  miscarriage  nine  months  previously,  the 
patient  having  before  this  enjoyed  good  health. 

Character  of  Menstruation. —  There  is  nothing  characteristic  in  the 
menstrual  histories  of  patients  who  exhibit  intermenstrual  pain.  Very 
often  menstruation  is  associated  with  dysmenorrhea,  although  this  is  almost 
always  described  as  much  less  severe  than  the  intermenstrual  pain.  As  far 
as  the  periodicity  and  amount  of  the  flow  are  concerned,  there  would  seem 
to  be  no  especial  influence,  variations  in  this  regard  being  attributable  to 
accompanving  pelvic  lesions  of  one  form  or  another. 

Associated  Pelvic  Lesions. —  In  perhaps  the  majority  of  cases  inter- 
menstrual pain  occurs  in  women  who  suffer  with  some  form  or  other  of 
pelvic  disease.  Often  the  lesion  is  of  trivial  nature,  wdiile  at  other  times  it 
is  of  much  greater  significance.  Frequently  no  abnormality  is  discoverable 
in  the  pelvis,  even  on  the  most  careful  examination.  Even  when  pelvic 
lesions  are  found,  moreover,  a  causative  role  cannot  be  attributed  to  them, 
especially  in  view  of  the  fact  that  the  location  of  the  intermenstrual  pain 
often  bears  no  relation  to  that  of  the  lesion. 

Etiology. —  Practically  nothing  of  a  definite  nature  is  known  con- 
cerning the  etiology  of  this  interesting  disorder.  Many  theories  have  been 
advanced  to  explain  it.  Some  of  them  are  quite  grotesque,  and  none  of 
them  can  be  accepted  as  proved.  Among  the  palpably  far  fetched  views 
may  be  mentioned  that  of  Drennan,  wdio  believes  the  pain  is  due  to  the 
escape  of  the  non-impregnated  ovum  through  the  cervical  canal,  thus  caus- 
ing painful  expulsive  contractions  of  the  uterus.  The  majority  of  authors 
attribute  the  pain  to  one  form  or  another  of  pathological  change  in  the 
pelvic  organs.  Thus,  Rosner  is  of  the  opinion  that  the  cause  is  a  chronic 
pelvic  congestion,  brought  about  by  a  vasomotor  disturbance  of  ovarian 
origin.  Fehling  believes  that  there  is  always  an  associated  chronic  inflam- 
matory process  in  the  uterus  and  ovaries.  Palmer  considers  the  cause  to 
be  oophoritis  or  perioophoritis,  which  prevents  the  rupture  of  the  graafian 
follicles.  Addinsell  looks  upon  profluent  salpingitis  as  the  cause  in  the  4 
cases  which  he  reports.  Many  other  authors  might  be  quoted  who  support 
the  anatomic  explanation  of  the  condition, 


INTERMENSTRUAL  PAIN  227 

The  striking  periodicity  of  the  disorder  makes  it  seem  almost  certain 
that  it  is  of  ovarian  origin.  The  former  view  of  the  relation  between  men- 
struation and  ovulation,  which  assumed  that  they  occur  synchronously, 
presented  an  obstacle  to  the  hypothesis  that  ovulation  might  be  the  cause 
of  intermenstrual  pain.  Heaney  believes  that  the  intermenstrual  pain  really 
represents  an  effort  at  menstruation,  the  type  of  which  is  thus  changed  from 
a  four  week  to  a  two  week  interval.  Our  newer  knowledge  of  the  relation 
between  menstruation  and  ovulation,  as  set  forth  in  Chapter  XVI,  makes 
unnecessary  these  hypotheses.  It  is  now  quite  generally  accepted  that  ovu- 
lation does  not  occur  at  the  menstrual  period,  but  at  a  period  varying  prob- 
ably from  about  the  seventh  to  the  fourteenth  days  of  the  menstrual  cycle. 
In  other  words,  intermenstrual  pain  is  commonly  observed  at  about  the  time 
of  normal  ovulation,  which  almost  surely  plays  an  important,  perhaps  an 
essential  part,  in  its  causation.  Just  what  the  abnormality  of  ovulation  is 
that  produces  pain  in  these  patients  cannot  be  stated.  Certainly  normal 
ovulation  is  not  associated  with  pain.  After  all,  then,  the  question  is  still 
an  open  one,  although  I  feel  that  the  advances  being  made  in  our  knowledge 
of  the  ovarian  function  will  aid  materially  in  the  solution. 

Treatment. —  Since  we  know  so  little  of  the  etiology  of  intermen- 
strual pain,  it  is  not  surprising  that  its  treatment  is  far  from  satisfactory. 
In  the  first  place,  the  cure  of  any  important  pelvic  lesions,  whether  by 
operation  or  otherwise,  is  of  importance,  especially  when  they  are  causing 
other  symptoms  in  addition  to  the  intermenstrual  pain.  Other  than  this, 
the  treatment  consists  principally  in  the  relief  of  pain,  just  as  in  the  treat- 
ment of  an  attack  of  dysmenorrhea.  Rest  in  bed,  together  with  hot  appli- 
cations to  the  seat  of  pain,  is  of  importance.  In  the  less  severe  cases, 
such  drugs  as  aspirin  or  the  various  coal  tar  products  may  give  the  desired 
relief.  In  the  more  severe  forms,  codein  or  perhaps  even  morphin  may  be 
necessary  to  control  the  pain,  although,  it  need  not  be  said,  such  drugs 
should  be  handled  with  the  greatest  caution,  in  order  to  avoid  habit 
formation. 

To  show  the  multiplicity  of  measures  which  have  been  used  in  the  treat- 
ment of  intermenstrual  pain,  I  can  do  no  better  than  to  quote  Kelly's  sum- 
mary of  the  results  of  treatment  in  the  cases  which  he  collected  from  the 
literature.  He  says  "Of  the  various  modes  of  treatment  adopted,  the 
results  are  as  follows :  Dilatation  and  curettage  was  tried  in  eleven  cases, 
entirely  without  benefit,  except  in  one  instance  where  the  uterus  was 
steamed  out  after  it,  and  in  this  case  the  intermenstrual  pain  had  lasted  but 
a  few  months.  Ovarian,  parotid,  and  thyroid  extracts  were  given  in  one 
case  without  relief,  but  in  another  the  thyroid  alone  was  followed  by  com- 
plete recovery.  Electricity  over  the  ovarian  region  was  tried  in  four  cases, 
two  of  which  were  somewhat  improved,  while  the  other  two  derived  no 
benefit  whatever.  Removal  of  one  ovary  and  tube  was  tried  in  four  cases 
where  the  localization  of  pain  in  the  ovarian  region  seemed  to  Indicate  it. 
In  one  instance  the  pain  was  relieved  for  a  period  of  eight  years,  and  in 


228  MENSTRUATION  AND  ITS  DISORDERS 

another  it  has  now  been  absent  for  six;  the  other  two  cases  were  entirely 
unbenefited.  The  appendages  were  removed  on  both  sides  in  five  cases, 
two  of  which  were  among"  the  cases  mentioned  where  one  ovary  was  first 
removed  without  benefit.  The  resuhs  in  one  instance  are  not  definitely 
stated,  although,  judging  from  the  context,  they  were  good;  of  the  other 
four  cases,  three  were  entirely  relieved  and  the  other  not  at  all.  In  the 
latter  instance,  however,  menstruation  continued  after  the  operation  and  it 
is  to  be  supposed  that  some  ovarian  tissue  remained  behind.  Suspension  of 
the  uterus  was  tried  in  three  cases  of  retrodisplacement,  with  complete 
relief  in  one  case,  partial  relief  in  another,  and  none  at  all  in  the  third. 

"  Partial  relief  was  also  obtained  in  three  cases  from  a  course  of  baths  or 
medicinal  waters ;  in  one  case  from  absolute  rest  in  bed  during  the  attacks 
of  pain,  with  straightening  of  the  uterus,  which  was  in  extreme  anteflexion ; 
and  in  one  case  from  the  use  of  a  Hodge  pessary  for  extreme  anteflexion, 
together  with  the  relief  of  a  coexisting  endometritis. 

"  Complete  relief  resulted  in  one  case  from  the  use  of  an  intrauterine 
pessary  for  marked  anteflexion ;  in  two  cases  from  a  six  months'  treatment 
for  endometritis,  nature  not  stated ;  in  one  case  from  the  cure  of  an  eroded 
cervix ;  and  in  one  from  rest  in  bed  during  the  attacks,  with  support  of  the 
uterus  by  tampons." 


XXI 

LITERATURE 

Addinsell.     Intermenstrual  Pain.     Brit.  M.  J.,  1898,  i,  692. 

Croom.     Mittelschmerz.     Edinb.  M.  J.,  1896,  i,  703. 

Drennan.     Intermenstrual  Pain.     Medical  News,  1903,  82,  68. 

Heaney.     Periodic  Intermenstrual  Pain.     Surg.  Gyn.  and  Obst,  1910,  11,  361. 

Kelly.     Medical  Gynecology.     N.  Y.,  1908. 

Marsh.     Intermenstrual  Phenomena,  with  Theories.     Amer.  J.  Obst.,   1897, 

36,  64. 
Newell.     Intermenstrual  Pain.     J.  Iowa  Med.  Soc,  1916,  6,  469. 
Palmer.     Periodic  Intermenstrual  Pain.     Am.  J.  Obst.,  1892,  26,  470. 
Priestly.     Causes  of  Intermenstrual  or  Intermediate  Dysmenorrhea.     Brit. 

M.  J.,  1872,  2,  431. 
Perrefoy.     Intermenstrual  Pain.     Med.  Press  and  Circ.  (Lend.),  1909,  87,  11. 
Rosner.     Des  douleurs  intermenstruelles.     Gynecologic  (Paris),  1905,  10,230. 
Sheill.     Intermenstrual  Pain.     Med.  Press  and  Circ,  1909,  87,  34. 
Still.     Intermenstrual  Pain.     Brit.  M.  J.,  1898,  i,  817. 
Theilhaber.     Zur  Pathologic  und  Therapie  des  Sogenannten  Mittelschmerzen. 

Arch.  f.  Gyn.,  1911,93,  554. 


CHAPTER  XXII 
UTERINE  HEMORRHAGE 

General  Considerations. —  The  study  of  uterine  bleeding  is  given  a 
peculiar  interest  by  the  fact  that  the  uterus  is  the  only  organ  in  the  body 
from  which  a  periodic  hemorrhage  occurs  as  a  physiologic  phenomenon. 
The  logical  point  of  departure  in  the  investigation  of  pathologic  uterine 
hemorrhage,  therefore,  would  seem  to  be  a  study  of  the  normal  type  of 
uterine  bleeding,  that  is,  menstruation.  In  the  study  of  all  the  menstrual 
disorders  the  tendency  has  been  to  lose  sight  of  the  fact  that  there  are  many 
links  in  the  menstrual  chain,  and  to  emphasize  some  one  factor  at  the 
expense  of  others,  which  may  be  equally  important.  As  regards  the  ex- 
planation of  uterine  bleeding,  it  is  the  anatomic  point  of  view  which  has 
received  most  attention.  This  is  not  surprising  when  we  consider  that  up 
to  very  recent  times  our  knowledge  of  the  menstrual  process  has  been 
much  more  highly  developed  along  anatomic  than  along  physiologic  lines, 
and  that  structural  alterations  in  an  organ  are  far  easier  to  demonstrate 
than  aberrations  of  function.  More  and  more,  however,  we  are  beginning 
to  realize  that  the  uterus  is  only  a  keyboard  on  which  many  variations  are 
played  by  a  complicated  menstrual  mechanism,  whose  ramifications  extend 
far  beyond  the  confines  of  the  pelvic  cavity.  Not  only  the  uterus,  but  all 
the  other  constituent  parts  of  the  menstrual  apparatus  as  well,  are  subject 
to  disturbances  of  one  form  or  another,  and  hence  none  of  them  should  be 
overlooked  in  the  investigation  of  uterine  hemorrhage  of  obscure  causation. 
The  causes  of  menorrhagia,  i.  e.,  excessive  bleeding  at  the  menstrual  periods, 
and  of  metrorrhagia,  i.  e.,  intermenstrual  bleeding,  may  conveniently  and 
properly  be  discussed  together. 

Relative  Importance  of  Anatomic  and  Physiologic  Factors. —  At  the 
outset  it  may  be  conceded  that  in  the  majority  of  instances  the  cause  of 
uterine  bleeding  is  anatomic,  in  some  cases  very  frankly  so.  For  example, 
uterine  cancer  is  a  perfectly  obvious  cause  of  bleeding  from  the  uterus,  just 
as  rectal  cancer  may  cause  bleeding  from  the  bowel.  The  same  clear  rela- 
tionship is  seen  in  the  case  of  a  few  other  lesions,  more  especially  those  of 
neoplastic  type.  We  may  thus  distinguish,  first  of  all,  a  type  of  uterine 
hemorrhage  clearly  due  to  well  defined  and  easily  demonstrable  causes  in 
one  part  or  another  of  the  uterus.  There  would  be  hemorrhages  from 
lesions  of  this  type,  even  though  there  were  no  such  thing  as  menstruation  to 
cause  a  periodic  flareup  in  the  pelvis. 

A  second  group  of  cases  may  be  distinguished  in  which  a  lesion  of  some 

229 


230  MENSTRUATION  AND  ITS  DISORDERS 

sort  exists  either  in  the  uterus  or  in  the  adnexa,  but  in  which  hemorrhage 
would  probably  not  occur,  were  it  not  for  the  extra  congestion  which  each 
menstruation  brings  with  it.  A  tubal  inflammatory  mass  or  an  ovarian 
neoplasm  might  not  in  itself  be  capable  of  producing  hemorrhage,  but  it 
frequently  exaggerates  the  menstrual  hjpQi-emis.,  and  hemorrhage  is  the 
result.  \A'hen  metrorrhagia  or  intermenstrual  bleeding  occurs,  it  would 
seem  at  first  thought  to  indicate  a  direct  effect  of  the  lesion  itself  on  the 
pelvic  circulation.  This,  however,  does  not  necessarily  follow,  for  it  is 
possible,  as  some  have  contended,  that  in  many  of  these  cases  the  disturb- 
ance of  the  menstrual  mechanism  is  much  more  fundamental,  involving  the 
function  of  the  ovary  itself. 

Finally,  there  is  a  third  group  of  cases  in  which  uterine  hemorrhage  occurs 
in  the  entire  absence  of  any  clearly  demonstrable  disease  in  any  of  the 
pelvic  organs,  and  in  which  the  explanation  must  be  sought  in  some  abnor- 
mality of  function  rather  than  of  anatomic  structure.  Numerically  speak- 
ing, cases  of  this  type  make  up  perhaps  the  smallest  group,  but  they  are  of 
considerable  importance  nevertheless. 

Classification  of  Causes  of  Uterine  Bleeding. —  It  will  be  recalled 
(Chapter  VII)  that  the  factors  concerned  in  menstruation  are  ( i)  an  under- 
lying cause,  dependent  upon  the  endocrin  activity  of  the  ovary,  and  influ- 
enced by  other  endocrin  organs  as  well;  (2)  a  nervous  mechanism, 
essentially  vasomotor  in  nature;  and  (3)  the  uterus,  and  especially  the 
endometrium.  In  addition,  the  state  of  general  health  also  exerts  an  influ- 
ence upon  the  function  of  menstruation,  as  will  be  discussed  in  a  later 
chapter  (Chapter  XXV).  The  important  point  to  bear  in  mind  is  that 
uterine  bleeding  may  be  due  to  a  disorder  of  any  of  the  factors  named,  and 
that  an  intelligent  study  of  a  given  case  must  embrace  a  search,  not  for 
anatomic  alterations  alone,  but  for  deviations  from  the  normal  physiology 
as  well.  From  this  standpoint,  the  causes  of  uterine  bleeding  may  be  con- 
sidered under  the  following  heads:  (i)  General  or  constitutional;  (2) 
Anatomic;  (3)  Fundamental  or  internal  secretory;  (4)  Nervous. 


CONSTITUTIONAL  CAUSES  OF  UTERINE  HEMORRHAGE 

As  in  the  case  of  other  menstrual  disturbances,  uterine  hemorrhage,  es- 
pecially menorrhagia,  may  at  times  be  noted  in  connection  with  general 
diseases,  even  when  the  generative  organs  themselves  are  normal.  Among 
the  more  important  general  conditions  which  may  be  influential  in  increas- 
ing the  menstrual  flow  may  be  mentioned  the  following : 

Acute  Infectious  Diseases. —  Acute  infectious  diseases,  such  as  typhoid 
fever,  pneumonia,  influenza,  the  exanthemata,  etc.  More  frequently  the 
tendency  of  these  diseases  is  to  inhibit  or  lessen  the  menstrual  flow,  but 
occasionally  an  opposite  effect  may  be  produced. 

Constitutional  Diseases. —  Constitutional  diseases,  such  as  anemia, 
diabetes,  syphilis,  hemophilia,  scurvy,  etc.     In  the  case  of  the  first  two, 


UTERINE  HEMORRHAGE  231 

menorrhagia  seems  to  be  less  frequent  than  amenorrhea.  In  certain  in- 
stances, however,  the  associated  lowering  of  vitality  appears  to  bring  about 
an  increased  permeability  of  the  blood  vessels,  which  perhaps  explains  the 
menstrual  excess. 

Organic  Diseases. —  Organic  diseases,  such  as  pulmonary  tuberculosis, 
hepatic  cirrhosis,  chronic  valvular  disease  of  the  heart,  and  chronic 
nephritis,  especially  when  associated  with  high  blood  pressure  and  other 
pronounced  manifestations  of  cardiovascular  disease. 

Chronic  Intoxications. —  Chronic  intoxications  of  various  kinds  are 
said  to  produce  excessive  menstruation  in  certain  instances.  Under  this 
head  would  be  placed  chronic  alcoholism,  phosphorus  poisoning,  lead 
poisoning,  etc. 

The  relation  of  general  disease  to  uterine  hemorrhage  is  discussed  at 
greater  length  in  Chapter  XXV. 

ANATOMIC  CAUSES  OF  UTERINE  HEMORRHAGE 
Polypi. —  These  may  spring  from  either  the  cervix  or  the  body  of  the 
uterus.  In  either  case  they  may  be  a  source  of  uterine  bleeding.  The 
cervical  polyp  is  often  associated  with  endocervicitis.  The  bleeding  to 
which  it  gives  rise  is  usually  independent  of  the  menstrual  cycle,  i.  e.,  it  is 
more  likely  to  be  a  metrorrhagia  than  a  menorrhagia,  though  both  are  often 
noted.  Such  patients  observe  that  coitus,  long  periods  of  standing,  heavy 
lifting  or  other  severe  exertions  are  apt  to  be  followed  by  the  appearance 
of  a  bloody  discharge,  sometimes  slight  in  amount,  in  other  instances  rather 
abundant.  In  some  cases,  especially  of  large  cervical  polypi,  the  menstrual 
flow  itself  is  excessive. 

Cervical  Polypi. —  Cervical  polypi  are  often  palpable  on  vaginal  exam- 
ination, as  tit-like  protrusions  from  the  cervical  canal.  They  are  most 
frequently  quite  small,  perhaps  no  larger  than  a  small  pea ;  often  they  are 
multiple.  Their  small  size,  together  with  their  soft  consistency  and  their 
movability,  makes  it  easy  to  overlook  them  unless  direct  inspection  is  made 
of  the  cervix  through  a  bivalve  speculum.  They  can  then  be  seen  peeping 
out  of  the  cervical  canal  a  greater  or  less  distance,  depending  on  the  length 
of  the  pedicle.  The  bright  red  color  of  the  polyp  is  in  sharp  contrast  to 
the  dull  opaque  hue  of  the  pars  vaginalis.  Occasionally  cervical  polypi 
become  quite  large. 

The  common  cervical  polyp  is  made  up,  histologically,  of  the  same  ele- 
ments as  the  normal  cervical  tissue,  of  which  it  is  only  a  heaping  up.  The 
glands  are  often  more  or  less  dilated,  and  are  lined  by  the  characteristic 
high,  slender  epithelium  of  the  cervix.  Normal  cervical  epithelium  covers 
the  surface  of  the  polyp,  although  it  is  often  lost  through  superficial  ulcera- 
tion. The  covering  epithelium  is  either  columnar  or  stratified  squamous, 
depending  on  the  level  from  which  the  polyp  springs.  The  stroma  is 
edematous  and  rich  in  blood  vessels.  The  vascularity  of  these  little  growths 
explains  the  bleeding  which  they  produce. 


232  MENSTRUATION  AND  ITS  DISORDERS 

CoRroREAL  Polypi. —  In  the  most  extreme  cases,  the  entire  endometrium 
may  be  involved  in  a  polypoid  process,  giving  rise  to  the  so-called  polypoid 
or  fungous  endometritis,  first  described  by  Olshausen.  We  are  here  con- 
cerned, however,  with  the  discrete  polypoid  growths  which  are  often  found 
springing  from  the  endometrial  surface,  and  which  are  a  frequent  source  of 
uterine  hemorrhage.  In  contrast  to  cervical  polypi,  they  are  more  likely  to 
cause  menorrhagia  than  metrorrhagia.  Not  infrequently  the  hemorrhage 
is  excessive,  its  frequent  recurrence  weakening  the  patient  very  decidedly. 
When  the  polyp  is  large  and  possesses  a  long  pedicle,  it  pokes  its  way  out 
through  the  cervical  canal,  so  that  its  diagnosis  becomes  as  simple  as  that 
of  the  cervical  polyp.  Unless  this  occurs,  however,  its  recognition  is  not 
by  any  means  so  simple,  being  made  possible  only  by  curetting  or  perhaps 
even  vaginal  hysterotomy. 

The  polypi  found  in  the  body  of  the  uterus  are  of  two  principal  types, 
leaving  aside  those  associated  with  malignant  disease  of  the  uterus.  The 
majority  are,  as  in  the  case  of  the  cervix,  merely  localized  poutings  of  the 
endometrium,  from  which  they  differ  in  only  a  minor  way.  Frequently 
they  are  rich  in  gland  elements,  so  that  they  are  often  spoken  of  as  glandular 
polypi.  As  in  the  case  of  cervical  growths,  the  stroma  usually  shows  edema 
and  marked  vascularity,  with  inflammatory  infiltration  near  the  surface  of 
those  in  which  secondary  infection  has  occurred.  The  surface,  where  not 
destroyed  by  ulceration  or  sloughing,  is  lined  by  the  short  columnar  epithe- 
lium of  the  corpus  uteri,  which  is  also,  of  course,  continued  into  the  gland 
depths. 

Much  more  frequently  than  in  the  cervix,  polypi  of  the  corpus  are  myoma- 
tous in  nature.  This  group  will,  however,  be  considered  under  another 
head. 

Cervical  Ectropion  and  Erosion. —  A  frequent  result  of  cervical  lace- 
rations is  a  rolling  out  or  eversion  of  the  mucosa  of  the  cervical  canal,  a 
condition  sometimes  erroneously  spoken  of  as  erosion.  Endocervicitis  is 
almost  invariably  the  result,  being  characterized  clinically  by  persistent 
leucorrhea.  The  engorgement  of  the  everted  cervical  mucosa  is  sometimes 
the  predisposing  cause  of  slight  bloody  discharges  after  coitus,  or  possibly 
even  after  such  exertion  as  that  of  lifting,  etc.  The  same  thing  is  true  of 
the  genuine  erosion,  which  is  far  less  frequent,  and  in  which  there  is  an 
actual  destruction  of  the  superficial  tissues  of  the  cervix.  In  the  so-called 
papillary  erosion,  the  mucosa  is  thrown  up  into  many  papillary  elevations, 
covered  by  the  columnar  cer^acal  epithelium. 

Retention  of  Gestation  Products. —  Perhaps  the  most  frequent  cause 
of  uterine  hemorrhage  is  incomplete  abortion.  This  is  easy  to  understand 
when  one  considers  the  extreme  frequency  of  abortion,  both  spontaneous 
and  induced,  and  the  likelihood  of  some  of  the  products  being  retained. 
Sometimes  the  dead  embryo  itself  remains  in  the  uterus ;  more  frequently 
it  is  the  placenta  or  membranes. 

Clinical  Considerations. —  In  the  very  early  cases  the  woman  herself 


UTERINE  HEMORRHAGE  233 

may  be  unconscious  of  the  fact  that  she  has  been  pregnant  and  that  she  has 
aborted,  the  embryo  being  so  tiny  that  it  escapes  detection.  In  these  cases 
there  is  perhaps  a  delay  of  only  a  few  days  in  the  menstrual  period,  fol- 
lowed by  a  period  of  bleeding  which  often  does  not  exceed  the  normal  dura- 
tion of  menstruation,  for  which  it  is  thus  mistaken.  Pain  may  be  altogether 
absent.  On  the  other  hand,  when  pregnancy  is  more  advanced,  abortion  is 
characterized  by  a  greater  or  less  amount  of  cramp-like  pain  and  by  the 
occurrence  of  free  uterine  bleeding. 

As  a  rule  the  expulsion  of  the  fetus  is  preceded  by  a  more  or  less  abundant 
bloody  discharge,  which  may  persist  for  many  days,  and  perhaps  for  a 
number  of  weeks.  If  both  fetus  and  placenta  be  expelled,  the  bleeding 
usually  ceases  rather  promptly.  On  the  other  hand,  if  the  placenta  remains 
behind,  bleeding  may  continue  indefinitely.  While  in  some  cases  it  may  be 
surprisingly  slight,  in  others  it  is  alarming,  possibly  exsanguinating  the 
patient.  In  a  certain  number  of  instances  portions  of  the  placenta  may  be 
retained  for  long  periods  of  time  without  causing  any  bleeding.  In  a  recent 
case  of  my  own,  one  of  the  placental  cotyledons  had  been  left  behind  in  a 
case  of  full  term  delivery,  causing  no  symptoms  until  seven  weeks  later.  At 
this  time  there  was  a  sudden  profuse  uterine  hemorrhage,  necessitating 
immediate  emptying  of  the  uterine  cavity.  The  placental  mass  was  molded 
to  the  interior  of  the  uterus,  constituting  a  typical  placental  polyp.  The 
hemorrhage  in  such  instances  is  obviously  due  to  separation  of  the  partially 
organized  mass  by  the  expulsive  contractions  of  the  uterus. 

In  a  large  percentage  of  cases,  especially  of  the  early  group,  the  patient 
does  not  seek  medical  advice  until  long  after  the  abortion  has  occurred. 
She  may  even,  as  already  mentioned,  be  ignorant  of  having  been  pregnant. 
Hemorrhage  may  have  continued  for  many  weeks,  either  constantly  or 
intermittently.  In  such  cases  the  true  nature  of  the  intra-uterine  condition 
can  be  recognized  only  by  curetting.  If  the  curette  brings  away  the  char- 
acteristic dark  shreddy  tissue  which  makes  up  the  placental  structure,  the 
diagnosis  is  macroscopically  obvious.  Very  often,  however,  the  curetted 
tissue  cannot  be  distinguished  from  thickened  endometrium.  In  such 
instances  the  aid  of  the  microscope  must  be  invoked  in  making  the  diagnosis. 

Histological  Findings. —  The  histological  elements  which  justify  a 
diagnosis  of  a  preexisting  pregnancy  differ  according  to  the  stage  at  which 
the  latter  was  terminated  and  the  time  which  has  elapsed  since  the  occurrence 
of  the  abortion.  Sometimes  the  glands  of  the  endometrium  show  the 
exaggerated  hypertrophy  and  tortuosity  which  characterize  early  pregnancy. 
On  cross  section  the  lumina  are  scalloped,  the  epithelium  being  low  and  of 
one  cell  thickness.  The  angles  produced  by  the  infolding  of  the  glands 
may  be  covered  by  tuft-like  epithelial  masses  several  cells  thick.  This 
appearance  is  evidently  due  to  the  manner  of  section  of  these  protruding 
angles.  It  should  be  emphasized  that  the  presence  of  such  markedly  hyper- 
trophic glands  in  uterine  curettings  is  not  in  itself  pathognomonic  of  preg- 
nancy,  for  such  a  picture  may  be  closely  mimicked  by  an  exaggerated 


234 


MENSTRUATION  AND  ITS  DISORDERS 


premenstrual  reaction  in  the  endometrium  in  the  absence  of  pregnancy.  On 
the  other  hand,  this  histological  picture  should  always  excite  suspicion,  and 
should  always  impel  one  to  make  a  careful  search  for  other  elements  which 
are  more  distinctive  of  pregnancy. 

Another  link  in  the  chain  of  evidence  is  at  times  obtainable  from  the 
appearance  of  the  stroma.  Curettings  removed  postabortum  commonly 
contain  larger  or  smaller  fields  of  decidual  cells.  The  latter,  as  is  well 
known,  are  merely  the  hypertrophied  stromal  cells  of  the  endometrium. 


Fig.  36. —  Curettings  from  a  Case  op  Incomplete  Abortion. 

The  upper  half  of  the  photograph  shows  a  number  of  somewhat  degenerated  chorionic 
villi,  while  the  lower  portion  is  taken  up  by  a  broad  field  of  decidual  cells,  presenting  a 
mosaic-like  appearance. 


As  in  the  case  of  the  uterine  glands,  a  moderate  degree  of  hypertrophy  is 
often  noted  in  the  stromal  cells  in  the  premenstrual  period,  giving  them  a 
decidua-Iike  appearance  (decidua-ahnliche  zellen).  When  the  cells  are 
large  and  ovoid,  with  a  broad  zone  of  protoplasm  surrounding  the  nucleus, 
so  that  they  resemble  cartilage  cells,  the  diagnoisis  of  a  preceding  pregnancy 
is  reasonably  certain.  In  outspoken  cases  the  decidual  cells  occur  in  broad 
fields  of  mosaic  appearance.  (Fig.  36.)  In  cases  in  which  considerable 
time  has  elapsed  since  the  abortion  they  may  occur  only  in  patches  here  and 


UTERINE  HEMORRHAGE  235 

there.  They  often  form  thick  mantles  around  the  endometrial  blood  ves- 
sels, which,  furthermore,  not  infrequently  exhibit  marked  endothelial  pro- 
liferation or  a  rather  characteristic  perivascular  "  fibrinoid  "  appearance. 

The  most  distinctive  element  in  the  diagnosis,  and  the  only  one  which, 
theoretically  at  least,  is  absolutely  pathognomonic  of  pregnancy,  is  the  pres- 
ence of  cJiorionic  villi.  (Fig.  36.)  Being  a  part  of  the  embryo  itself,  their 
diagnostic  value  is  absolute.  Except  when  the  abortion  has  been  very 
recent,  the  villi  are  more  or  less  degenerated.  Indeed,  in  many  instances 
only  their  outline  is  discernible  —  the  so-called  "  shadow  villi  "  or  "  ghost 
villi."  In  a  large  proportion  of  cases,  to  be  sure,  chrionic  villi  are  not 
found  at  all.  In  these,  however,  the  presence  of  one  or  more  of  the  elements 
above  described,  i.  e.,  characteristic  decidual  cells,  pregnancy  glands,  blood 
vessel  changes,  etc.,  makes  the  diagnosis  quite  certain.  It  may  be  added 
that  with  the  pregnancy  pictures  in  the  endometrium  there  is  often  combined 
that  of  chronic  endometritis,  with  round  cell  infiltration  of  the  stroma.  In 
the  more  recent  cases,  polymoTphonuclear  leukocytes  are  present  in  abund- 
ance. 

Endometritis. —  Up  to  the  time  of  our  newer  knowledge  of  endo- 
metrial histology,  i.  e.,  up  to  the  time  of  the  investigations  of  Hitschmann 
and  Adler,  In  1908,  chronic  endometritis  was  quite  generally  looked  upon 
as  an  extremely  frequent  disease.  It  was,  furthermore,  held  responsible  for 
many  cases  of  uterine  hemorrhage,  as  well  as  of  leukorrhea.  We  know 
now,  however,  that  chronic  endometritis  is  a  relatively  infrequent  condition. 
For  example,  only  48  instances  were  found  by  Cullen  in  an  examination  of 
1800  curettings.  The  gland  changes  upon  which  the  diagnosis  O'f  chronic 
endometritis  was  formerly  based  we  now  know  are  purely  physiological  in 
character. 

Not  only  is  chronic  endometritis  uncommon,  but  it  is  not  easy  to  under- 
stand how  it  can  produce  uterine  bleeding  even  when  it  does  occur.  The 
thickening  of  the  endometrium  and  the  preponderance  of  interstitial  tissue 
in  it  might  even  lead  one  to  suppose  that  the  menstrual  hemorrhage  would 
be  less  abundant  than  normal.  Be  that  as  it  may,  the  fact  remains  that  in 
a  certain  number  of  cases,  chronic  endometritis  is  found  to  be  associated 
with  uterine  hemorrhage.  For  the  present  it  must  remain  a  question  as  to 
whether  the  hemorrhage  in  these  cases  is  due  to  the  endometritis  or  to  asso- 
ciated lesions,  whether  these  be  anatomic  or  physiologic  in  character. 
Hitschmann  and  Adler  are  strongly  of  the  opinion  that  chronic  endometritis, 
while  it  may  cause  leukorrhea,  is  never  in  itself  a  cause  of  hemorrhage.  My 
own  work  inclines  me  strongly  to  the  same  belief.  The  same  authors  lay 
stress  upon  the  essential  importance  of  the  so-called  plasma  cell  in  the 
microscopic  diagnosis  of  chronic  endometritis. 

Hyperplasia  of  the  Endometrium. —  In  1900  and  at  various  times 
since  then,  Cullen  called  attention  to  an  interesting  condition  of  the  endome- 
trium with  which  uterine  bleeding  is  always  associated  clinically.  To  this 
condition  the  designation  of  hyperplasia  of  the  endometrium  was  given,  at 


236  MENSTRUATION  AND  ITS  DISORDERS 

the  suggestion  of  Dr.  William  H,  Welch.  It  occurs  most  frequently  at  ot 
near  the  time  of  the  menopause,  and  next  most  frequently  in  young  girls 
within  the  first  few  years  of  menstrual  life.  It  may,  however,  be  encoun- 
tered at  any  period  during  the  reproductive  life.  The  characteristic  clinical 
symptom  is  excessive  and  prolonged  menstruation.  Metrorrhagia  is  much 
less  frequent. 

Grossly  the  mucosa  is  usually  much  thicker  than  normal,  and  not  infre- 
quently presents  a  shaggy  or  even  markedly  fungous  appearance.  The 
hyperplastic  change  seems  to  affect  both  the  epithelium  and  the  stroma. 
The  former  is  distinctly  thickened,  the  nuclei  being  heavily  stained  and 
closely  crowded,  at  times  giving  the  impression  of  a  number  of  distinct 
layers.  The  glands  are  uneven,  some  being  narrow,  some  moderately  tor- 
tuous, and  some  very  much  dilated,  appearing  like  small  cysts.  (Fig.  37.) 
That  the  overdistention  of  the  glands  is  not  due  to  mere  retention  of  their 
contents  is  indicated  by  the  fact  that  the  lining  epithelium,  instead  of  being 
flattened  out,  is  often  quite  high.  The  smoothness  of  the  walls  and  the  lack 
of  tortuosity  in  these  large  dilated  glands  gives  them  a  characteristically 
rigid  or  parchment-like  appearance.  The  stroma  gives  the  impression  of 
compactness  and  overabundance.  Its  hyperplastic  activity  is  often  indicated 
by  the  presence  of  mitoses.  Although  karyokinetic  figures  are  common 
in  the  epithelium  of  the  uterus,  they  are  almost  never  observed  in  the  normal 
stroma.  Another  finding  of  great  frequency  is  the  presence  of  numerous 
thromboses,  as  well  as  of  large  veins  distended  with  blood,  and  perhaps  of 
hemorrhagic  extravasations  in  the  tissues. 

H3^perplasia  of  the  endometrium  is  the  common  finding  "in  cases  of  so- 
called  "  functional  "  or  "  idiopathic  "  uterine  bleeding,  and  there  is  good 
reason  to  believe  that  it  is  purely  secondary  to  an  endorine  disorder,  prob- 
ably of  the  ovaries.  This  subject  is  discussed  under  the  head  of  functional 
hemorrhage. 

Muscular  InsufBciency  of  the  Uterus. —  It  was  Scanzoni  who,  in 
i860,  first  directed  attention  to  the  mesometrium  as  a  factor  in  the  causation 
of  uterine  hemorrhage.  In  his  M^ork,  "  Ueber  die  Chronische  Metritis,"  he 
argued  that  chronic  metritis  frequently  exists  as  a  disease  of  the  uterine 
musculature  even  when  the  mucosa  is  normal.  According  to  him  chronic 
metritis  is  the  most  common  of  female  diseases,  a  view  which  is  now  obso- 
lete. He  described  the  disease  as  consisting  of  a  primary  stage  of  hyperemia 
and  serous  infiltration,  followed  by  one  of  induration.  These  observations, 
of  course,  were  enunciated  before  the  days  of  the  modern  microscope.  In 
addition  to  the  changes  in  the  myometrium,  Scanzoni  described  an  increase 
in  the  brittleness  of  the  arteries,  which  he  held  to  be  primarily  responsible 
for  the  hemorrhage. 

Theilhaber,  in  more  recent  years,  has  also  emphasized  the  importance  oi 
the  mesometrium  in  both  normal  and  pathological  uterine  hemorrhage. 
He  uses  the  term  "  mesometrium  "  in  order  to  embrace  the  connective  tissue 
as  well  as  the  muscle,  only  the  latter  being  indicated  by  the  word  "  myome- 


UTERINE  HEMORRHAGE 


237 


Fig.  37. —  Hyperplasia  of  the  Endometrium. 
The  section  is  a  portion  of  a  scraping.  The  surface  epithelium  is  intact,  as  seen  at  a 
and  a.  At  b  are  two  normal  uterine  glands.  Fully  half  of  the  glands  are  more  or  less 
dilated.  At  c  is  an  irregular  and  dilated  gland,  filled  with  coagulated  serum,  d  and  e  are 
also  dilated,  but  not  spherical  glands.  The  gland  f  is  markedly  dilated  and  spherical.  In 
none  of  the  dilated  glands  is  there  any  atrophy  of  the  epithelium.  The  stroma  between  the 
glands  is  very  dense.  In  some  of  these  cases  large  veins  are  scattered  throughout  the 
stroma.  Given  such  a  mucosa  as  this,  one  can  say  with  almost  absolute  certainty  that  the 
patient  has  had  very  profuse  menstrual  bleeding  (Cullen). 


238  MENSTRUATION  AND  ITS  DISORDERS 

trium."  He  asserts  that  contraction  of  the  uterine  wall  plays  an  important 
rule  in  regulating  the  pelvic  circulation,  not  only  during  pregnancy,  but 
throughout  the  reproductive  life  of  the  woman.  If  the  contractility  is 
defective,  various  pathological  changes  occur,  the  leading  symptom  of  which 
is  a  tendency  to  hemorrhage  from  the  mucosa.  He  further  states  that  the 
proportion  of  muscle  to  connective  tissue  varies  according  to  the  age  of  the 
individual.  In  childhood  and  in  old  age  there  is  a  preponderance  of  connec- 
tive tissue  over  muscle,  while  the  blood  vessels  are  small.  During  the 
reproductive  life  of  the  woman,  on  the  other  hand,  there  is  less  connective 
tissue  and  more  muscle,  w^hile  the  blood  vessels  are  large.  A  pathological 
defect  of  muscle  or  an  excess  of  connective  tissue  during  reproductive  life  is 
the  essential  lesion  in  many  conditions  characterized  by  hemorrhagic  dis- 
charge. To  this  general  condition  Theilhaber  gives  the  name  of  "  insuffi- 
cientia  uteri." 

In  this  same  group  of  causes  may  be  placed  that  described  by  Anspach, 
who,  under  the  name  of  "  metrorrhagia  myopathica,"  describes  a  form  of 
uterine  bleeding  which  he  attributes  to  a  failure  of  the  normal  increase  in 
the  elastic  tissue  which  takes  place  toward  the  close  of  menstrual  life,  or  of 
the  normal  obliterative  changes  in  the  blood  vessels,  or  an  excessive  hyper- 
trophy of  connective  tissue,  making  firm  contraction  of  the  uterus  and 
consequent  compression  of  the  blood  vessels  impossible.  In  this  way  are 
produced  disturbances  of  the  endometrial  circulation  and  profuse  menor- 
rhagia  or  metrorrhagia. 

Arteriosclerosis  of  the  Uterine  Vessels. —  Much  importance  has  been 
attributed  to  this  factor  by  Pankow,  Reinecke,  and  a  number  of  other 
authors.  The  blood  vessel  changes  described  by  Pankow,  from  an  exam- 
ination of  55  uteri,  involved  the  smaller  arteries  of  the  mesometrium  and 
endometrium,  and  consisted  in  an  increase  in  the  elastic  fibres  of  the  vessels, 
as  well  as  of  the  uterus  itself.  These  changes  were  observed  only  in  the 
uteri  of  women  who  had  borne  children.  Age  apparently  played  nO'  part, 
for  they  were  found  even  in  very  young  women.  These  alterations  differ 
from  those  commonly  noted  in  senility  in  that  the  latter  involve  larger 
vessels  by  preference. 

Similar  studies  have  been  made  by  Reinecke,  Herman,  Martin,  Kiistner, 
Slocum,  von  Kahlden,  Findley,  and  others.  The  designation  of  "  apoplexia 
uteri  "  was  applied  to  these  cases  by  Cruveilhier.  The  tendency  of  many 
gynecologists  in  the  past  seems  to  have  been  to  consider  that  all  cases  of 
uterine  bleeding  for  which  no  other  explanation  could  be  found  were  prob- 
ably due  to  uterine  arteriosclerosis.  So  far  as  I  know,  all  the  reported  cases 
of  uncontrollable  uterine  hemorrhage  ascribed  to  arteriosclerosis  were  in 
patients  who  had  not  yet  passed  the  menopause,  and,  as  Barbour  wisely 
says,  "  arterosclerosis  after  the  menopause  has  been  very  frequently  de- 
scribed, but  never  as  accompanied  by  serious  hemorrhage."  It  is  obviously 
difficult,  and  sometimes  impossible,  to  eliminate  other  possible  causes  in  the 
consideration  of  these  cases.     No  evidence  has  as  yet  been  presented  which, 


UTERINE  HEMORRHAGE  239 

to  my  mind,  justifies  us  in  ascribing  more  than  an  occasional  role  to  this 
cause. 

Carcinoma  of  the  Uterus. —  In  all  forms  of  cancer  of  the  uterus  by 
far  the  most  important  symptom  is  bleeding.  Especially  true  is  this  of  the 
cervical  forms,  i.  e.,  squamous  cell  carcinoma  and  adenocarcinoma  of  the 
cervix.  The  early  stages  of  these  growths  are  characterized  by  numberless 
fine  filiform  outgrowths  from  the  surface  of  the  cervix,  either  on  the  pars 
vaginalis,  or  in  the  cervical  canal,  as  the  case  may  be.  These  consist  of  a 
slender  stem  of  stroma,  bearing  one  or  more  thin  walled  vessels,  and  covered 
by  a  delicate  epithelial  surface.  Their  structure  explains  why  the  slightest 
trauma,  such  as  that  produced  by  coitus,  or  by  straining  efforts,  may  result  in 
bleeding.  At  first  this  is  slight  and  intermittent,  but  as  the  cancerous 
process  continues  it  becomes  continuous  and  sometimes  very  profuse.  In 
the  later  stages  the  hemorrhage  is  due  in  large  measure  to  the  ulcerative 
process  of  the  disease. 

In  adenocarcinoma  of  the  body  hemorrhage  is  somewhat  less  frequent 
than  in  cervical  cancer,  although  even  here  it  is  the  most  important  symptom. 
The  lesser  frequency  of  bleeding  in  cancer  of  the  corpus  uteri  is  explained 
by  Cullen  as  due  to  the  fact  that  the  corporeal  growths  are  less  vascular 
than  those  in  the  cervix,  and  that  they  are  well  protected  from  external 
trauma.  The  vital  importance  of  suspecting  cancer  in  all  cases  of  uterine 
hemorrhage  at  or  near  the  age  of  the  menopause  is  emphasized  in  Chapter 
XIV. 

Sarcoma  of  the  Uterus. —  While  far  less  frequent  than  carcinoma, 
sarcoma  may  occasionally  be  encountered  in  either  the  cervix  or  the  body  of 
the  uterus.  The  symptoms  are  in  a  general  way  similar  to  those  of  carci- 
noma. As  in  the  case  of  the  latter,  bleeding  is  the  most  important  symptom. 
It  does  not  usually  appear  until  ulcerative  processes  begin,  and  hence  may 
not  be  so  early  a  symptom  as  it  usually  is  with  carcinoma. 

Hydatidiform  Mole. —  This  form  of  obstetrical  hemorrhage  is  occa- 
sionally encountered  by  the  gynecologist.  It  is  a  disease  of  the  chorion 
characterized  by  two  principal  changes,  viz.,  abnormal  proliferation  of  the 
trophoblast  and  hydropic  degeneration  of  the  stroma.  The  latter  change  is 
responsible  for  the  distention  of  the  villi  which  gives  rise  to  the  character- 
istic grape-like  appearance  of  the  mole. 

Clinically  the  condition  manifests  itself  by  uterine  bleeding  coming  on 
usually  in  the  first  few  months  of  pregnancy.  It  is  therefore  commonly 
mistaken  for  threatened  abortion.  Suspicion  of  hydatidiform  mole  is  justi- 
fied, if  the  uterus  is  enlarged  beyond  the  size  which  is  to  be  expected  from 
the  duration  of  the  pregnancy.  The  passage  of  grape-like  vesicles  from 
the  uterus  makes  the  diagnosis  certain.  In  one  of  my  cases  the  diagnosis 
was  made  from  one  such  tiny  vesicle  which  adhered  to  the  finger  of  the 
examining  hand  on  withdrawal  from  the  vagina. 

Chorio-epithelioma. —  Whenever  bleeding  persists  after  the  removal 
of  a  hydatidiform  mole,  one  should  suspect  the  development  of  the  malignant 


240 


MENSTRUATION  AND  ITS  DISORDERS 


tumor  of  chorionic  epithelium,  i.  e.,  chorio^epithelioma.  The  latter  may 
develop  also  after  normal  pregnancy  or  abortion.  In  either  event  the 
important  symptom  is  uterine  hemorrhage. 

Microscopically,  chorio-epithelioma  is  made  up  of  cells  from  both  layers 
of  the  trophoblast,  i.  e.,  the  syncytium  and  the  layer  of  Langhans.  The 
alveolar  arrangement  of  the  cells  around  large  blood  spaces  is  quite  char- 
acteristic. The  tumor  is  very  invasive  and  forms  early  metastases.  Since 
the  elements  which  make  it  up  do  not  themselves  differ  from  the  cells  of  the 
normal  trophoblast  or  of  a 
hydatidiform  mole,  a  diag- 
nosis of  chorio-epithelioma 
cannot  safely  be  made  from 
curettings. 

Uterine  Myoma  and 
Adenomyoma. —  The  most 
important  symptom  of  uterine 
myoma  is  uterine  hemorrhage, 
manifesting  itself  usually  as 
menorrhagia.  This  is  also 
true  of  adenomyoma  of  the 
uterus.  Both  the  amount  and 
the  duration  of  menstruation 
are  likely  to  be  increased.  The 
influence  of  myomata  upon  the 
menstrual  function  depends 
upon  their  size,  and,  even 
more,  upon  their  location. 
Speaking  generally,  the  sub- 
serous growths  are  much  less 
likely  to  cause  excessive  men- 
struation than  either  the  intra- 
mural or  submucous  tumors. 
The  latter  are  especially  apt  to 


Fig. 


38. —  Eadiograph  of  the  Arterial  Supply 
THE  Entire  Uterus,  X  1. 


or 


,                    •        J         •  1.            z  Nullipara  aged  25 ;  arteries  injected  with  bismuth 

be     associated     with     profuse  subcarbonate ;  autopsy  specimen.     The  course  of  each 

bleedinp"  uterine  artery  is  shown  along  the  side  of  the  uterus, 

r~.  .          .  .  and     from    these     the    intrinsic    uterine     (arcuate) 

This    subject    has    been    ex-  arteries  arise  (Sampson). 

haustively  studied  by  Samp- 
son by  means  of  the  injection  method.  He  divides  the  uterine  wall  into 
three  zones:  first,  the  peripheral  (outer  third),  which  is  nourished  by  what 
he  calls  the  "peripheral  arteries;"  second,  the  arcuate,  the  narrow  zone  in 
whieh  the  "arcuate  vessels"  lie;  and,  third,  the  radial  (inner  two  thirds), 
which  is  nourished  by  the  "  radial  arteries."  (Figs.  38  and  39.)  Bleeding 
from  myomata,  he  explains,  is  due  not  only  to  congestion  of  the  endometrial 
venous  plexus  from  which  the  normal  menstrual  discharge  emanates,  but 
even  more  to  a  loss  of  efficiency  of  the  uterine  musculature. 


UTERINE  HEMORRHAGE 


241 


He  gives  the  following  summary  of  the  menstrual  histories  in  the  series 
of  150  cases  of  uterine  myoma  studied  by  him:  "Forty-seven  of  the 
patients  gave  a  history  of  not  having  had  any  disturbances  in  menstruation. 
Of  these,  22  had  small  intramural  and  some  small  subserous  myomata;  17, 
medium  size  and  large  intramural  myomata;  5,  adenomyomata  and  small 
intramural  myomata;  2,  large  subserous  and  small  intramural  myomata; 
and,  I,  a  subserous  and. small  intramural  myoma. 

"  Sixty-four  gave  a  history  of  profuse  menstruation,  often  prolonged,  i.  e., 
the  so-called  menorrhagia,  as  the  predominating  type  of  abnormal  bleeding. 


Fig.  39. —  Arterial  Supply  of  the  Uterine  Tissues,  XI. 

Eadiograph  of  a  cross  slice  3  mm.  thick  of  the  body  of  the  uterus.  Nullipara,  aged  34; 
arteries  injected  with  bismuth;  uterus  removed  for  chronic  pelvic  peritonitis.  The  arcuate 
arteries,  the  large  arteries,  and  a  small  portion  of  a  third,  two  of  which  appear  in.  the 
illustration,  pass  between  the  outer  third  and  inner  two  thirds  of  the  uterine  wall  and 
terminate,  in  the  median  line,  in  radial  and  peripheral  branches.  They  divide  the  uterine 
wall  into  two  zones  —  the  outer  or  peripheral  zone,  which  is  nourished  by  peripheral 
branches  of  the  arcuate  arteries,  and  the  inner  or  radial  zone,  which  is  nourished  by  radial 
branches,  the  latter  terminating  in  the  endometrium  by  fine  capillaries.  Each  arcuate 
artery,  with  its  peripheral  and  radial  branches,  supplies  a  quadrantal  segment  of  the  uterus, 
corresponding  to  the  anterior  or  posterior  half  of  the  miillerian  duct  of  that  side.  When 
the  uterus  is  relaxed  arterial  blood  would  easily  gain  access  to  the  endometrium,  but  when 
contracted  it  would  seem  that  the  terminal  arterioles  and  capillaries  of  the  radial  arteries 
would  be  easily  compressed  (Sampson). 

Thirty-nine  of  these  had  intramural  tumors  encroaching  upon  the  uterine 
cavity  as  the  apparent  cause ;  in  10  a  submucous  tumor  v^as  present;  small 
intramural  tumors  not  encroaching  upon  the  uterine  cavity  were  found  in  9 ; 
adenomyoma  with  other  varieties  of  myomata  were  found  in  5  ;  small  intra- 
mural tumors  with  a  polyp  were  found  in  2. 

"  Thirty-nine  gave  a  history  of  irregular  bleeding,  i.  e.,  metrorrhagia,  as 
the  predominant  symptom.  Carcinoma  of  the  cervix  with  intramural  myo- 
mata was  found  in  8 ;  carcinoma  of  the  body  of  the  uterus  with  myomata  in 


242  MENSTRUATION  AND  ITS  DISORDERS 

5 ;  polypi  and  small  intramural  tumors  in  5 ;  small  intramural  myomata  not 
encroaching  upon  the  uterine  cavity,  4 ;  large  intramural  myomata,  3 ; 
adenomyomata  with  other  forms  of  myomata,  2 ;  tubal  pregnancy  and 
myomata,  3;  incomplete  abortion  with  myomata  and  infection  (one  puer- 
peral, the  other  probably  gonorrheal),  2;  hydatidiform  mole  with  myomata. 
I ;  sarcoma,  2.  This  grouping  shows  that  any  one  variety  may  or  may  not 
alter  menstruation,  and  that  the  bleeding  present,  especially  if  of  the 
metrorrhagic  type,  is  often  due  to  some  other  condition." 

Ectopic  Pregnancy. —  In  no  condition  is  the  menstrual  history  of 
greater  significance  than  in  ectopic  pregnancy.  The  classical  picture  is  that 
of  a  patient  who  has  missed  one  menstrual  period,  this  being  followed,  after 
a  period  of  from  a  few  days  to  several  weeks,  by  a  slight  but  persistent 
bloody  discharge.  Occasionally  the  period  of  amenorrhea  is  longer,  two 
menstrual  periods  being  missed.  ]\Iore  frequently,  however,  there  has  been 
no  amenorrhea  at  all,  a  bloody  discharge  making  its  appearance  perhaps  two 
or  three  weeks  after  a  normal  menstrual  period. 

The  characteristic  hemorrhage  is  of  the  "  spotting "  type,  the  patient 
noticing  perhaps  only  a  few  drops  of  blood  each  day.  In  many  cases,  how- 
ever, bleeding  is  quite  free.  Almost  always  it  is  accompanied  by  some  pain, 
more  marked  in  one  side  of  the  pelvis  than  the  other.  Sometimes  severe 
cramp-like  attacks  are  observed,  frequently  with  fainting.  As  in  intra- 
uterine pregnancy,  many  patients  experience  such  subjective  symptoms  as 
"  morning  nausea,"  vomiting,  irritability  of  the  bladder,  etc. 

Sampson  has,  by  the  injection  method,  studied  the  influence  of  ectopic 
pregnancy  on  the  blood  supply  of  the  uterus.  He  finds  that  in  these  cases 
the  uterus  is  enlarged,  as  a  result  of  hyperemia  and  a  thickening  of  the 
endometrium.  The  changes  in  the  latter  do  not  differ  materially  from  those 
seen  in  early  intra-uterine  pregnancy. 

Tuberculosis  of  the  Generative  Organs. —  The  most  frequent  seat  for 
tuberculosis  of  the  female  genitalia  is  the  fallopian  tube.  It  is  stated  that 
as  many  as  8  per  cent  of  all  cases  of  salpingitis  are  of  tuberculous  origin. 
In  the  great  majority  of  cases  tuberculosis  of  the  tube  is  secondary  to  a 
tuberculous  focus  elsewhere,  although  in  many  cases  the  primary  focus  is 
not  ascertainable.  In  some  cases  tubal  tuberculosis  is  only  an  incident  to 
tuberculosis  of  the  peritoneum,  in  which  case  the  tubal  involvement  may  for 
a  considerable  period  be  limited  to  the  serosa.  In  the  early  stages  of  tubal 
tuberculosis,  epithelial  proliferation  may  be  so  marked  that  a  branching 
gland-like  appearance  is  produced.  In  this  stage  the  condition  might  easily 
be  mistaken  for  carcinoma,  and  such  a  mistake  has  often  been  made.  In 
the  later  stages,  the  picture  is  more  characteristically  that  of  tuberculosis, 
with  tubercles,  giant  cells,  caseation,  etc. 

Tuberculosis  of  the  endometrium  is  practically  always  secondary  to  tuber- 
culous salpingitis.  Owing  to  the  normal  cellular  structure  of  the  endome- 
trium, tubercles  of  the  latter  do  not  always  stand  out  so  sharply  as  in  most 
other  tissues.     In  other  cases  they  may  be  quite  conspicuous. 


UTERINE  HEMORRHAGE  243 

Uterine  bleeding  is  not  an  invariable  accompaniment  of  pelvic  tubercu- 
losis, but  it  occurs  quite  frequently.  As  in  tuberculous  disease  elsewhere, 
the  associated  general  debility  may  produce  amenorrhea,  especially  in  those 
cases  which  are  secondary  to  disease  in  the  lungs  or  elsewhere.  Speaking 
generally,  excessive  menstruation  may  be  looked  upon  as  evidencing  a  pre- 
dominance of  the  local  disease  over  the  general,  while  amenorrhea  more 
commonly  is  found  in  late  stages,  with  profound  deterioration  of  the  general 
health. 

The  uterine  bleeding  of  genital  tuberculosis  is  practically  always  associated 
with  dysmenorrhea,  usually  of  a  severe  type.  These  two  symptoms,  espe- 
cially when  they  occur  together  in  young  unmarried  women,  and  are  asso- 
ciated with  persistent,  even  though  slight  evening  fever,  should  lead  to  the 
suspicion  of  pelvic  tuberculosis.  Further  investigation  —  careful  family 
history,  examination  of  the  chest,  a  well  kept  temperature  and  pulse  record, 
tuberculin  tests  —  will  often  confirm  this  suspicion. 

Inflammatory  Disease  of  the  Adnexa. —  In  some  cases  of  adnexitis, 
menstruation  may  be  normal  in  amount  and  rhythm ;  in  others  it  is  exces- 
sive in  amount,  with  or  without  irregularity  of  rhythm.  It  is  rarely  dimin- 
ished in  amount.  The  varying  effects  of  tubo-ovarian  inflammatory  disease 
upon  menstruation  are  explained  by  Hitschmann  and  Adler  as  being  depend- 
ent upon  involvement  or  non-involvement  of  the  ovary  in  the  inflammatory 
process.  While  not  as  yet  entirely  proved,  this  view  has  much  to  support  it. 
Certainly  it  is  in  accordance  with  our  conception  of  the  mechanism  of  the 
normal  menstrual  bleeding. 

Tumors  of  the  Ovary. —  The  most  common  tumors  of  the  ovary  are 
the  cysts.  These  may  be  subdivided  into  (i)  graafian  follicle  cysts;  (2) 
corpus  luteum  cysts;  (3)  cystadenomata  or  multilocular  cysts;  (4)  papillo- 
matous cysts;  (5)  teratomata,  including  dermoid  cysts. 

The  first  two  groups  never  reach  a  large  size,  and  appear  to  exert  little 
effect  on  menstruation.  It  has  been  stated  that  corpus  luteum  cysts  are 
always  associated  wuth  uterine  bleeding,  but  a  recent  study  of  my  own  has 
shown  the  incorrectness  of  this  view.  Multilocular  cysts,  as  is  well  known, 
may  reach  a  huge  size,  while  the  remaining  two  groups,  i.  e.,  the  papillo- 
matous and  teratomatous  cysts,  may  also  become  quite  large. 

The  effect  on  menstruation  of  any  of  the  tumors  depends  on  the  size  of 
tl^e  tumors,  on  whether  they  are  unilateral  or  bilateral,  and  on  the  amount 
of  ovarian  destruction  they  entail.  In  some  instances  menstruation  is  un- 
impaired, in  others  it  is  excessive,  while  in  still  others  it  may  be  deficient  or 
absent  altogether.  The  last  named  phenomenon  is,  according  to  my  experi- 
ence, more  likely  to  be  observed  with  dermoids  than  with  other  ovarian  cysts, 
perhaps  because  they  are  so  frequently  bilateral. 

Of  the  solid  tumors  of  the  ovary  the  most  Important  are  the  malignant 
ones,  i.  e.,  sarcoma  and  carcinoma.  The  former  may  be  observ'ed  even  in 
young  children.  Carcinoma  may  be  primary,  but  is  more  commonly  second- 
ary, especially  to  pyloric  cancer.     This  is  especially  so  in  the  case  of  the 


244  MENSTRUATION  AND  ITS  DISORDERS 

so-called  Krukenberg  tumor.  Benign  solid  tumors  are  rare,  fibromata  being 
more  frequent  than  myomata,  contrary  to  the  rule  in  the  uterus.  In  none 
of  these  tumors  is  there  any  characteristic  effect  upon  menstruation, 
although  excessive  bleeding  is  not  uncommon. 

Tumors  of  the  Tube. —  New  growths  in  the  fallopian  tubes  are  rare, 
but  when  they  occur,  they  are  often  associated  with  uterine  bleeding.  Of 
primary  tubal  neoplasms  the  most  important  is  carcinoma,  of  which  a  con- 
siderable number  of  cases  have  been  reported. 

INTERNAL  SECRETORY  CAUSES  OF  UTERINE 
HEMORRHAGE 

Hypersecretion   of   Ovary    (Hyperoophorism,    Hypergonadism). — 

It  is  with  the  ovary  that  we  are  primarily  concerned  in  the  con- 
sideration of  the  internal  secretory  causes  of  menstruation.  The 
study  of  the  ovarian  hormone,  like  that  of  the  other  internal  secretions, 
is  much  easier  along  negative  than  along  positive  lines.  To  illustrate,  by 
mere  extirpation  of  the  ovaries,  we  may  show  that  cessation  of  menstruation 
is  due  to  loss  of  the  ovarian  hormone.  But  it  is  far  more  difficult  to  bring 
about  a  condition  of  hyperfunction  of  the  ovaries ;  nor  is  it  even  certain  that 
such  a  condition  of  "  hyperoophorism,"  analagous  to  hyperthyroidism,  may 
be  produced.  In  the  case  of  the  thyroid,  mere  feeding  of  the  gland  extract 
to  a  normal  person  suffices  to  bring  about  hyperthyroidism.  On  the  other 
hand,  the  possibility  of  producing  hyperoophorism  by  feeding  ovarian  ex- 
tract is  open  to  question.  This  is  perhaps  not  surprising  when  we  consider 
how  little  we  know  concerning  the  nature  and  characteristics  of  the  ovarian 
hormone  or  hormones,  and  how  gradual  and  inconspicuous  would  probably 
be  the  effect  of  an  excess  of  ovarian  secretion,  even  though  we  were  sure 
that  this  could  be  produced  by  mere  feeding  of  the  extract.  A  number  of 
cases  have  been  recorded  in  which  hyperoophorism  has  apparently  been 
brought  about  by  the  latter  method.  A  rather  striking  case  in  the  recent 
literature  is  that  of  Adler.  It  was  that  of  a  girl  of  21,  who  had  menstruated 
normally  since  the  age  of  15,  but  who  after  a  short  course  O'f  an  ovarian 
extract  for  the  first  time  in  her  life  menstruated  four  days  before  the 
expected  time,  the  flow  being  much  more  profuse  and  lasting  longer.  After 
the  cessation  of  the  treatment,  menstruation  resumed  its  old  periodicity, 
duration  and  amount. 

Much  more  interesting,  however,  is  the  effort  of  Adler  to  determine  the 
existence  of  hyperoophorism  in  an  indirect  manner.  His  method  requires 
a  word  oi  explanation.  As  with  the  other  viscera,  the  principal  nerve 
supply  of  the  uterus  is  derived  from  the  sympathetic.  A  very  revolutionary 
change  is  now  in  progress  as  regards  our  ideas  of  the  physiology  of  the 
sympathetic  nervous  system,  or,  as  it  is  frequently  called,  the  vegetative 
system.  According  to  the  classical  description  of  Langley,  the  entire  vege- 
tative system  may  be  divided  intO'  two  portions.  First,  there  is  the  gangliated 


UTERINE  HEMORRHAGE  245 

cord  which  stretches  along  each  side  of  the  midhne  of  the  body,  and  which 
may  be  cahed  the  sympathetic  system  proper.  Secondly,  many  of  the  auto- 
nomic functions  of  the  body  are  in  part  regulated  by  certain  cerebrospinal 
nerves  derived  principally  from  the  brain  and  from  the  sacral  portion  of  the 
spinal  cord.  These  nerves  constitute  what  is  therefore  called  the  cranio- 
sacral autonomic  system.  From  the  fact  that  the  vagus  nerve  is  the  most 
prominent  constituent,  this  system  is  also  spoken  of  as  the  vagal.  Kraus, 
again,  speaks  of  it  as  the  parasympathetic.  The  distinction  between  the  two 
systems  can  perhaps  be  best  illustrated  by  the  case  of  the  heart.  This  organ 
receives  its  accelerator  supply  from  the  sympathetic,  its  inhibitory  supply 
from  the  vagus.  The  former  is  the  whip  of  the  heart,  the  latter  the  brake. 
This  antagonism  in  function  is  characteristic,  being  noted  in  all  the  other 
organs,  including  the  uterus. 

To  proceed  to  the  practical  application  of  these  facts,  it  has  been  found 
that  certain  drugs  show  an  elective  affinity  for  one  or  the  other  of  the  two 
systems.  Epinephrin,  in  accordance  with  the  well  known  law  of  Langley, 
affects  especially  the  sympathetic,  its  injection  causing  precisely  the  same 
efifect  on  an  organ  as  does  stimulation  of  its  sympathetic  nerve  supply.  It 
is  therefore  spoken  of  as  a  sympathicotropic  drug.  On  the  other  hand, 
pilocarpin  is  perhaps  the  best  known  of  a  group  of  drugs  which  exert  a 
special  action  on  the  vagal  system,  and  which  are  therefore  spoken  of  as 
vagotropic  drugs.  To  carry  the  point  still  farther,  it  has  been  found  that 
certain  endogenous  chemical  substances  of  the  body,  more  particularly  the 
various  hormones,  exhibit  a  special  influence  on  one  or  the  other  of  these 
two  systems.  There  is  reason  to  believe  that  before  very  long,  all  the 
various  hormones  of  the  body  will  be  divisible  into  two  groups,  one  sympathi- 
cotropic, the  other  vagotropic.    Much  has  already  been  done  along  this  line. 

Studies  on  the  ovarian  hormone  from  this  point  of  view  are  still  very 
meager.  The  observations  of  Adler,  however,  are  worthy  of  mention. 
After  removal  of  the  ovaries,  and  to  a  less  extent  in  cases  of  ovarian  insuffi- 
ciency manifesting  themselves  by  amenorrhea  and  genital  hypoplasia,  he 
found  that  there  is  an  increased  susceptibility  to  small  doses  of  the  sympathi- 
cotropic epinephrin.  On  the  contrary,  in  the  study  of  a  series  of  cases  of 
uterine  bleeding,  he  observed  no  reaction  whatsoever  to  epinephrin,  while  on 
the  other  hand  there  was  a  marked  susceptibility  to  even  very  small  doses  of 
the  vagotropic  pilocarpin.  This  result  he  regards  as  justifying  the  view 
that  these  cases  of  uterine  bleeding  were  due  to  overfunction  of  the  ovary. 

This  conclusion,  however,  is  open  to  serious  question,  when  we  consider 
that  many  structures  other  than  the  ovary  contribute  to  the  characteristic 
reactions.  Even  so,  however,  such  work  as  this  is  of  exceeding  value. 
For  perhaps  the  first  time,  we  are  now  able  to  attack  the  hitherto  rather 
intangible  problem  of  the  internal  secretions  by  simple  clinical  methods 
instead  of  by  complicated  laboratory  investigation.  Just  what  practical 
results  will  accrue  from  this  new  line  of  endeavor  remains  to  be  seen. 

Disorders  of  Other  Endocrin  Glands  Than  Ovary. —  In  addition  to 
the  ovary,  practically  all  the  other  endocrin  structures  are  also  to  a  greater 


246  MENSTRUATION  AND  ITS  DISORDERS 

or  less  extent  linked  up  with  the  menstrual  function,  and  hence  may  at  times 
be  responsible  for  uterine  bleeding.  This  subject  is  discussed  in  Chapter 
XXIV. 

Local  Factor  in  Endometrium. —  Another  physiologic  factor  in  the 
causation  of  uterine  hemorrhage  which  is  closely  associated  with  the  activity 
of  the  glands  of  internal  secretion  has  reference  to  the  presence  of  some 
local  factor  in  the  endometrium  which  is  capable  of  diminishing  the  coagu- 
lability of  the  blood  and  thus  predisposing  to  bleeding.  Sturmdorf  has 
suggested  that  the  endometrium,  under  the  influence  of  the  ovarian  hormone, 
manufactures  a  substance  which  inhibits  the  normal  coagulability  of  the 
blood.  The  experimental  work  of  Schickele  and  others  has  led  to  some- 
what similar  conclusions.  Schickele's  results  are  based  on  the  study  of  the 
inhibiting  influences  of  extracts  and  expressed  juices  of  the  uterus  and 
ovaries  on  the  coagulability  of  the  blood.  When  there  was  no  abnormal 
bleeding  from  the  uterus,  he  found  that  the  inhibitory  powers  of  the  ovarian 
extracts  were  greater  than  those  of  the  uterus ;  but  when  profuse  menstrual 
bleeding  was  present,  it  was  found  that  the  extracts  from  the  uterus  exerted 
a  much  greater  inhibiting  effect  on  coagulation.  This  would  seem  to  indi- 
cate that  bleeding  is  associated  with  the  accumulation  of  coagulation  inhibit- 
ing substances  in  the  endometrium.  Without  going  into  greater  detail,  I 
need  only  say  that  the  work  of  Schickele  indicates  that  the  inhibiting  sub- 
stances are  formed  in  the  ovaries  and  given  off  in  the  uterus.  When  uterine 
bleeding  is  present,  there  is  an  excessive  amount  of  these  inhibiting  substances 
in  the  uterus.  Schickele  suggests  that  this  is  probably  due  to  overactivity 
of  the  ovary,  so  that  ultimately  this  local  physiologic  factor  in  the  causation 
of  the  bleeding  is  apparently  traceable  to  a  fundamental  disturbance  in  the 
mechanism  of  the  menstrual  process.  The  occasional  success  of  the  opera- 
tion of  curettage  in  the  relief  of  uterine  hemorrhage,  even  when  the  endo- 
metrium is  anatomically  normal,  may  perhaps  be  explained  on  the  basis  of 
this  work,  the  good  result  being  due  to  the  removal  of  the  inhibiting 
substance  rather  than  of  the  endometrium. 

Functional  Uterine  Bleeding. —  There  is  a  form  of  uterine  hemor- 
rhage which  is  often  observed  in  the  entire  absence  of  any  demonstrable 
pelvic  disease.  This  type  of  bleeding  has  been  spoken  of  variously  as 
"  functional,"  "  idiopathic,"  or  "  essential  "  uterine  hemorrhage.  It  is  es- 
pecially common  at  puberty  ("hemorrhage  of  puberty")  and  at  the  meno- 
pause ("  climacteric  "  or  "  menopausal  "  hemorrhage).  By  far  the  largest 
number  of  cases  is  observed  at  or  about  the  menopausal  age.  The  very 
great  practical  bearing  of  this  fact  is  obvious,  in  that  one  is  frequently 
called  upon  to  distinguish  between  functional  hemorrhage  and  that  due  to 
early  carcinoma.  This  distinction  is  usually  possible  by  means  of,  and  only 
by  means  of,  the  microscope.  Although  most  common  at  the  two  extremes 
of  menstrual  life,  functional  uterine  hemorrhage  may  occur  at  any  period 
during  the  reproductive  life  of  the  woman.  The  bleeding  is  characteristic- 
ally of  the  type  of  menorrhagia,  rather  than  metrorrhagia,  although  the  latter 


UTERINE  HEMORRHAGE  247 

occasionally  occurs.  In  some  of  these  cases,  however,  the  metrorrhagia  is 
apparent  rather  than  real,  the  menstrual  periods  being  so  much  prolonged 
that  bleeding  is  practically  constant.  In  itself  there  is  no  pain  associated 
with  this  form  of  uterine  hemorrhage.  It  is  interesting  to  note  that  in 
these  cases  menstruation  is  often  delayed,  and  it  is  not  infrequent  to  observe 
periods  of  amenorrhea,  lasting,  in  some  cases,  as  long  as  several  months. 

Various  explanations  have  been  offered  for  the  mechanism  of  this  form  of 
menstrual  disturbance.  Some  have  explained  it  as  due  to  arteriosclerosis 
of  the  uterine  vessels,  some  as  due  to  an  "  insufficientia  uteri  "  (Theilhaber), 
some  as  due  to  an  uterine  myopathy,  etc.  None  of  these  various  theories, 
however,  has  seemed  adequate  to  explain  this  form  of  hemorrhage.  In  a 
recent  paper  I  emphasized  the  fact  that  a  common  histological  finding  in 
these  so-called  functional  cases  of  uterine  bleeding  is  the  condition  desig- 
nated as  hyperplasia  of  the  endometrium  (see  page  235). 

The  Role  of  the  Endocrine  Glands. —  The  finding  in  these  cases  of  such 
a  definite  structural  alteration  as  hyperplasia  would  seem  at  first  thought  to 
speak  against  the  functional  nature  of  the  bleeding.  We  must  bear  in  mind, 
however,  that  the  endometrium  is,  as  it  were,  only  the  creature  of  the  ovary. 
Certainly  the  remarkable  cyclic  changes  of  the  uterine  mucosa  which  are 
associated  with  normal  menstruation  are  directly  due  to  the  internal  secre- 
tory activity  of  the  ovary.  If  the  latter  be  disordered,  it  is  natural  to  assume 
that  the  endometrial  response  will  also  be  abnormal.  In  the  functional 
hemorrhage  which  we  are  now  considering,  the  ovarian  secretion  is  com- 
monly believed  to  be  disturbed,  whether  primarily  or  secondarily.  The  fact 
that  the  endometrium  in  such  cases  shows  the  typical  hyperplasia,  suggests 
therefore  that  the  latter  may  be  merely  the  result  of  the  disturbed  endocrine 
function.  A  number  of  interesting  facts  bearing  on  this  question  may  be 
submitted. 

1.  Functional  uterine  hemorrhage,  as  already  stated,  may  occur  at  any 
age  during  menstrual  life,  but  it  is  most  common  at  puberty  and  the  meno- 
pause, especially  at  the  latter  period.  Exactly  the  same  statement  may  be 
made  of  hyperplasia  of  the  endometrium. 

2.  Hyperplasia  with  excessive  menstruation  sometimes  occurs  in  veiy 
young  individuals,  in  whom  the  possibility  of  an  inflammatory  etiology 
may  reasonably  well  be  ruled  out.  Recently  I  observed  a  typical  case  in 
a  girl  of  twelve  years,  who  had  had  profuse  uterine  bleeding  for  three 
months.  The  occurrence  of  hyperplasia  in  these  very  young  patients, 
together  with  the  frequent  presence,  in  such  cases,  of  other  endocrinopathic 
stigmata,  points  to  a  probable  endocrine  origin.  The  histological  picture 
above  described  as  characteristic  of  hyperplasia  of  the  endometrium  has 
been  described  by  some  as  of  inflammatory  origin.  Driessen,  for  example, 
speaks  of  it  as  "  endometritis  necrobiotica."  There  does  not  seem  to  me, 
however,  to  be  the  slightest  justification  for  such  a  belief.  Certainly  there 
is  no  microscopic  evidence  of  inflammation  in  the  typical  hyperplastic 
endometrium. 


248  MENSTRUATION  AND  ITS  DISORDERS 

3.  It  is  only  during  the  reproductive  life  of  the  woman  —  that  is,  during 
the  period  of  ovarian  activity  —  that  both  hyperplasia  and  functional  bleed- 
ing are  found.  They  disappear  after  the  menopause  and  may  always  be 
checked  by  removal  of  the  ovaries.  Occasionally  curetting,  in  cases  of 
uterine  bleeding  occurring  several  months  after  apparent  menopause,  may 
yield  a  hyperplastic  endometrium.  These  cases  are  analogous  to  the  not 
infrequent  instances  of  pregnancy  occurring  after  apparent  menopause. 
They  are  apparently  to  be  explained  by  the  fact  that  cessation  of  ovarian 
function  is  not  actually  complete.  Or,  as  Schroder  suggests,  it  is  possible 
that  the  endocrine  disturbance  involves  other  endocrine  glands  than  the 
ovary. 

4.  Hyperplasia,  and  the  associated  menstrual  bleeding,  are  not  usually 
cured  by  curettage.  Observations  on  this  point  are  still  rather  meager, 
owing  to  the  fact  that  this  endometrial  condition  has  not  as  yet  gained 
general  recognition  as  a  histological  entity.  The  results  of  Schickele  and 
Keller  are,  however,  of  interest  in  this  connection.  Of  iii  curettings  per- 
formed for  uterine  bleeding,  38  were  successful  and  61  were  failures. 
Among  the  38  successful  cases,  there  were  only  4  hyperplasias  (10  per  cent). 
Of  the  61  unsuccessful  cases,  9  were  hyperplasias  (15  per  cent).  Good 
results  are  too  often  taken  for  granted  when  patients  with  functional  bleed- 
ing are  curetted.  Most  frequently  this  assumption  is  not  borne  out  by  the 
subsequent  history  of  the  patient.  Busse  found  only  10  per  cent  of  actual 
cures  in  506  cases  of  curettage  for  uterine  hemorrhage  due  to  various  causes. 
He  did  not  differentiate  the  cases  of  hyperplasia  in  his  statistics,  but  there 
is  no  doubt  that  a  great  many  were  included,  and  that  they  would  hardly 
show  better  results  than  the  general  average  above  quoted. 

5.  When  a  hyperplastic  endometrium  is  curetted  away  it  is  not  replaced 
by  a  normal  mucosa,  but  by  a  tissue  similar  to  that  removed.  This  is 
demonstrated  by  the  examination  of  sections  from  cases  in  which  curettage 
has  been  repeated  one  or  more  times.  The  deduction  to  be  drawn  from  this 
fact  is  that  the  lesion  is  not  a  local  one,  as  it  is,  for  example,  in  cases  of  the 
postabortive  type,  where  curettage  practically  always  brings  about  a  cessa- 
tion of  the  bleeding.  In  curetting  cases  of  hyperplasia,  on  the  other  hand, 
we  are  attacking  the  disease  at  the  wrong  end,  for  we  merely  remove  the 
endornetrial  manifestation  of  the  underlying  endocrine  cause,  which  still 
remains  operative. 

6.  In  a  certain  number  of  cases  curettage,  especially  if  repeated  a 
number  of  times,  may  result  in  cure.  In  these  cases  it  seems  likely  that 
either  spontaneously  or  as  a  result  of  the  operative  procedure  there  occurs 
a  readjustment  in  the  function  of  the  ovary. 

7.  Radium  and  the  X-ray,  which  destroy  the  graafian  follicles  in  the 
ovary,  exert  a  most  beneficial  effect  on  the  type  of  bleeding  under  consid- 
eration. 

8.  Even  if  hyperplasia  were  a  primary  disease  of  the  endometrium,  it 
would  be  difficult  to  suggest  any  satisfactory  explanation  of  the  uterine 


UTERINE  HEMORRHAGE  249 

bleeding  which  accompanies  it.  By  comparison,  the  hyperemia  in  cases  of 
hyperplasia  is  certainly  much  less  intense  than  in  such  conditions  as  acute 
endometritis,  and  yet,  in  the  latter,  menstruation  is  frequently  normal,  and 
may  be  absent  altogether.  In  other  words,  disease  of  the  endometrium 
without  involvement  of  the  ovary  is  not  characteristically  associated  with 
bleeding,  while  disease  of  the  ovary,  even  though  the  endometrium  be 
normal,  is  frequently  associated  with  excessive  menstruation. 

Is  Hyperplasia  a  Constant  Finding  with  Functional  Uterine  Hemorrhage? 
The  question  next  arises  as  to  whether  all  cases  of  functional  hemorrhage 
are  associated  with  hyperplasia  of  the  endometrium.  This  is  not  an  easy 
matter  to  determine,  inasmuch  as  the  exclusion  of  anatomic  causes  is  some- 
times impossible  clinically.  For  instance,  functional  hemorrhage  may  be 
due  to  a  concealed  uterine  polyp;  or  to  a  small,  unrecognized  myoma;  or 
to  an  early  carcinoma;  or  to  a  low  grade  adnexal  involvement.  Until  a 
much  larger  number  of  cases  is  studied,  therefore,  we  cannot  be  definite  on 
this  point.  The  impression  that  I  have  gained,  however,  from  the  study 
of  a  rather  large  number  of  cases,  is  that  unless  hyperplasia  is  found  on 
curetting,  we  should  not  be  too  quick  to  assume  the  functional  nature  of 
the  bleeding. 

Subservience  of  the  Endometrium  to  the  Ovary.  The  conception  that 
pathological  alterations  in  the  endometrium  may  be  of  ovarian  origin  is  not 
by  any  means  a  new  one.  Brennecke,  as  far  back  as  1882,  spoke  of  what 
he  called  "  endometritis  ovarialis."  Somewhat  similar  ideas  were  sug- 
gested by  Czempin,  Gottschalk  and  Franz.  These  observations  were  pub- 
lished before  the  epoch  making  work  of  Hitschmann  and  Adler  on  the 
menstrual  histology  of  the  endometrium,  and  there  is  no  doubt  that  the 
endometrial  changes  which  were  described  really  represent  various  stages 
of  the  premenstrual  hypertrophy  normally  exhibited  by  the  uterine  mucosa. 
These  earlier  observations  are  of  interest,  however,  in  that  they  indicate 
a  recognition  of  the  habitual  subservience  of  the  endometrium  to  the  ovary. 
Lauth  has  shown  that  the  injection  of  ovarian  extracts  may  cause  hyperemia 
and  hemorrhage,  together  with  definite  changes  in  the  endometrium  and 
myometrium. 

The  investigations  of  Schroder  are  especially  interesting  in  this  connec- 
tion, in  that  they  have  tO'  deal  directly  with  the  question  of  the  ovarian 
etiology  of  hyperplasia.  This  author,  from  a  study  of  54  cases,  concluded 
that  the  characteristic  ovarian  changes  consist  of  a  failure  of  follicular  rup- 
ture, and  a  consequent  absence  of  corpora  lutea  in  these  cases.  Inasmuch 
as  the  corpus  luteum  is  believed  to  be  essential  to  the  premenstrual  secretory 
stage  normally  exhibited  by  the  endometrium,  it  is  not  surprising  that  this 
secretory  stage  is  absent  in  cases  of  hyperplasia.  In  other  words,  there  is 
a  persistence  of  the  proliferative  stage,  which  Schroder  believes  is  due  to 
the  internal  secretory  activity  of  the  follicles.  To  put  it  in  other  words, 
the  development  of  the  endometrium  stops  short  of  the  secretory  stage,  the 
picture  of  hyperplasia  representing  merely  a  persistence  and  an  exaggeration 


250  MENSTRUATION  AND  ITS  DISORDERS 

of  the  proliferative  phase.     The  conclusions  of  Schroder  are  of  very  great 
interest,  but  they  still  lack  confirmation. 

The  Nature  of  the  Endocrinopathy.  As  yet  it  is  not  possible  to  state 
whether  the  ovarian  disorder  is  in  the  nature  of  excessive  or  of  diminished 
function.  Female  hypogonadism  is  a  frequent  and  well  defined  clinical 
entity,  being"  well  t^^Dified  by  the  phenomena  of  the  menopause,  either  natural 
or  surgical.  Much  less  is  known  as  to  the  opposite  condition  —  female 
hypergonadism,  or  hyperoophorism.  It  is  surprising  to  note  the  looseness 
with  which  this  term'  has  been  employed  by  various  authors.  There  is  no 
scientific  justification,  for  example,  for  ascribing  precocious  puberty  to 
excessive  secretion  of  the  ovary,  as  has  been  done  by  various  authors  — 
there  is,  indeed,  good  evidence  against  this  view.  In  the  absence  of  any 
structural  changes  in  the  pelvic  organs,  it  would  seem  logical  to  explain 
excessive  menstruation  as  being  due  to  excessive  ovarian  secretion,  but  this 
has  not  yet  been  demonstrated. 

Which  Ovarian  Element  is  Concerned?  It  is  not  very  satisfying,  in  the 
present  state  of  our  knowledge,  to  speculate  as  to  the  relative  importance, 
in  the  production  of  hyperplasia,  of  the  corpus  luteum  and  the  other  ovarian 
elements.  Two  apparently  incongruous  clinical  factors  have  struck  me  as 
bearing  on  this  point.  First,  the  bleeding  of  hyperplasia  is  characteristically 
in  the  nature  of  menorrhagia;  that  is,  the  periodicity  of  menstruation  is 
usually  preserved.  This  would  suggest  an  influence  on  the  part  of  the 
corpus  luteum,  which  is  preeminently  the  cyclical  structure  in  the  ovary. 
Secondly,  no  matter  at  what  period  the  endometrium  is  curetted  in  a  case  of 
hyperplasia,  the  histological  pattern  is  practically  the  same,  although  the 
degree  of  change  may  vary  considerably,  just  as  cases  vary  in  the  severity 
of  their  clinical  symptoms.  In  other  words,  the  endometrium,  in  cases  of 
hyperplasia,  does  not  exhibit  the  characteristic  cyclic  changes  seen  normally 
at  the  various  menstrual  epochs.  This  observation,  in  contrast  tO'  the  one 
previously  mentioned,  would  suggest  that  the  corpus  luteum  influence  is  in 
abeyance.  When  these  two  observations  are  explained  and  harmonized, 
the  problem  will  be  well  advanced  toward  solution.  After  all,  little  will 
be  gained  from  any  extended  discussion  of  the  etiology  of  hyperplasia  until 
we  know  more  concerning  the  nature  and  functions  of  the  ovarian  hor- 
mones—  I  use  the  plural  number  advisedly,  for  it  seems  certain  that  the 
ovary  possesses  more  than  one  hormone. 

The  Practical  Lesson  to  he  Draum.  Too  many  gynecologists  are  inclined 
to  explain  all  cases  of  uterine  hemorrhage  on  the  basis  of  some  definite 
structural  disease  in  the  pelvis,  without  taking  into  account  the  importance 
of  pathologic  physiology  as  a  possible  factor.  Menstruation  is  in  itself 
a  physiological  hemorrhage,  and  yet  no  one  would  maintain  that  it  is  due 
to  the  hypertrophic  endometrium  found  just  before  its  onset.  It  is  the 
ovarian  secretion  which  is  universally  accepted  as  the  ultimate  cause  of  the 
phenomenon.  Why  then  speak  of  an  important  group  of  cases  of  uterine 
hemorrhage  as  caused  by  hyperplasia,  or  even  by  a  "  local  biological  factor  " 


UTERINE  HEMORRHAGE  251 

in  the  endometrium,  when  both  the  liyperplasia  and  the  "  local  factor  "  are 
merely  manifestations  of  the  same  underlying  cause —  a  disordered  ovarian 
function  ? 


THE  NERVOUS  CAUSES  OF  UTERINE  HEMORRHAGE 

General  Considerations. —  We  come,  finally,  to  a  consideration  of  the 
nervous  causes  of  hemorrhage  from  the  uterus.  A  few  years  ago  it  would 
have  been  considered  only  a  fanciful  hypothesis  to  attribute  to  the  nervous 
system  a  part  in  the  causation  of  uterine  bleeding.  When  we  consider, 
however,  that  such  a  condition  as  exophthalmic  goiter  appears  often  to 
follow  severe  nervous  shock,  and  that  Crile  has  demonstrated  that  the  emo- 
tion of  fright  is  associated  with  definite  structural  alterations  in  the  brain 
cells,  we  must  certainly  have  greater  respect  for  the  nerv^ous  system  as  a 
disturber,  not  only  of  function,  but  also  of  structure.  There  are  many 
functions  of  the  body  which  are  essentially  autonomic,  but  in  which  a  vestige 
of  voluntary  control  is  still  evident.  In  defecation  and  micturition  the 
control  of  the  will  is  still  an  important  factor.  In  the  case  of  such  a  func- 
tion as  digestion,  the  voluntary  factor  is  far  less  important,  while  in  the 
case  of  menstruation,  to  go  still  farther,  the  influence  of  the  volitional  factor 
is  unrecognizable  under  normal  conditions.  And  yet  even  with  menstrua- 
tion the  higher  centers  still  retain  at  least  a  vestigial  degree  of  control,  and 
under  pathologic  conditions,  this  may  be  greatly  exaggerated. 

Vasomotor  Disturbance  Due  to  Nervous  or  Psychic  Influence. —  The 
nervous  factor  in  uterine  bleeding  has  already  been  touched  on  in  the  dis- 
cussion of  the  vegetative  nerves  as  they  influence  the  internal  secretion  of 
the  ovary.  It  is  scarcely  necessary  to  add  that  what  is  true  of  their  influence 
on  the  ovarian  secretion  is  equally  true  as  regards  their  influence  on  the 
other  internal  secretory  tissues.  No  one  can  as  yet  say  to  what  extent  the 
influence  of  these  various  internal  secretions  on  menstruation  is  directly 
chemical,  and  to  what  extent  it  is  exerted  through  the  medium  of  the  vaso- 
motor nerves.  Like  the  vasomotor  nerves  in  all  other  parts  of  the  body, 
those  supplying  the  generative  organs  arise  ultimately  from  the  cerebro^ 
spinal  axis,  the  primary  vasomotor  center  being  definitely  located  in  the 
floor  of  the  fourth  ventricle.  The  center  is  linked  up  with  the  psychic 
centers,  thus  explaining  the  occasional  occurrence  of  uterine  bleeding  as  a 
result  of  severe  emotional  disturbance  of  one  form  or  another.  A  number 
of  such  cases  have  come  under  my  own  observation,  of  which  the  two 
following  are  typical : 

A  woman  of  42,  a  multipara,  had  always  menstruated  regularly,  the  flow 
lasting  usually  about  four  days.  A  menstrual  period  commenced  December 
23,  191 3.  December  26,  as  the  flow  was  abating,  a  Christmas  tree  in  her 
home  took  fire,  setting  the  room  ablaze.  The  woman  received  a  severe 
fright,  and  within  a  short  while  a  profuse  hemorrhage  set  in,  lasting  for  six 
or  eight  hours,  and  then  gradually  abating. 


252  MENSTRUATION  AND  ITS  DISORDERS 

A  girl  of  15,  who  had  commenced  to  menstruate  at  13,  was  brought  to 
the  dispensary  with  profuse  uterine  bleeding.  Her  menstruation  had  never 
been  regular,  amenorrhea  being  frequently  noted.  There  had  never  previ- 
ously been  any  excessive  flow.  The  history  given  was  that  an  assault  on 
the  child  had  been  attempted  on  the  preceding  day.  On  account  of  the 
bleeding,  it  was  thought  that  there  might  have  been  some  local  injury. 
Examination  disproved  this,  the  assault  having  evidently  been  unsuccess- 
ful. Regular  menstruation,  lasting  three  days,  had  occurred  five  weeks 
previously.  The  hemorrhage  in  this  case  was  apparently  due  to  the  nerv- 
ous shock  associated  with  the  attempted  assault. 

A  number  of  other  cases  of  this  type  might  be  cited.  Similar  cases  are 
reported  by  Ehrenfest  and  others.  That  hemorrhage  may  be  of  neurotic 
origin  has  been  abundantly  shown  by  Brown-Sequard,  von  Recklinghausen 
and  others.  There  is  nothing  very  revolutionary  in  such  an  explanation, 
for  many  other  phenomena  might  be  mentioned  which  illustrate  the  in- 
fluence of  the  psyche  on  processes  which  in  themselves  are  essentially  auto- 
matic —  the  "  watering  "  of  the  mouth  at  the  sight  or  smell  of  food,  the 
acceleration  of  the  heart  from  fright  cr  joy,  the  sweating  so  characteristic 
of  intense  anxiety,  etc.  Even  more  apropos,  since  they  illustrate  the  in- 
fluence of  psychic  disturbances  on  the  vasomotor  apparatus,  are  such  phe- 
nomena as  the  blush  of  shame  or  embarrassment,  or  the  bleeding  from: 
the  stomach  or  even  from  the  skin  which  has  been  observed  in  highly 
nervous  or  hysteric  women.  From  a  theoretic  point  of  view  as  well  as 
from  clinical  experience,  we  may  therefore  conclude  that  certain  cases  of 
uterine  bleeding  are  undoubtedly  neurotic  in  origin,  or,  more  properly, 
perhaps,  "  angioneurotic." 

The  close  interlocking  of  the  nervous  system  and  the  ductless  glands 
make  it  possible  for  severe  psychic  disturbances  to  produce  menstrual  aber- 
rations by  a  direct  effect  on  the  functions  of  the  internal  secretory  glands. 
Such  a  phenomenon  would  be  analogous  to  the  glycosuria  which  has  been 
shown  to  occur  at  times  in  conditions  of  severe  fright  and  other  emotional 
disturbance,  and  which  is  explained  as  being  due  to  a  nervous  excitation 
of  the  adrenal  bodies.  This  has  been  corroborated  by  the  failure  of  the 
glycosuria  to  appear,  if  the  nerves  supplying  the  adrenals  have  previously 
been  cut,  thus  severing  the  connection  of  the  latter  with  the  psychic  centers. 
I  mention  this  to  emphasize  the  fact  that  a  direct  connection  between  the 
psychic  centers  and  the  ductless  gland  chain  has  been  demonstrated  experi- 
mentally. The  nervous  factor  in  uterine  hemorrhage,  like  that  of  the 
internal  secretions,  is  most  apt  to  make  itself  manifest  at  those  periods 
when  the  wom^an's  mental  equilibrium  is  already  unstable,  that  is,  at  puberty 
and  menopause. 

TREATMENT  OF  UTERINE  BLEEDING 

Treatment  of  Cause. —  It  is  almost  axiomatic  to  emphasize  that  the 
first  step  in  the  rational  treatment  of  uterine  bleeding  is  the  ascertainment 


UTERINE  HEMORRHAGE  "253 

of  the  cause,  and  its  removal  if  possible.  The  removal  of  polypi  or  of  a 
diseased  endometrium,  of  tumors  of  the  uterus  or  adnexa,  and  of  other 
causative  lesions  is  of  course  the  essential  step  in  the  treatment  of  the 
hemorrhage  for  which  they  are  responsible.  For  a  discussion  of  the  oper- 
ative measures  w^hich  may  be  indicated  in  these  cases,  I  would  refer  the 
reader  to  the  various  text  books  of  operative  gynecology. 

Constitutional  Treatment. —  In  all  forms  of  uterine  hemorrhage,  it  is 
of  importance  to  correct  any  constitutional  defect,  such  as  anemia,  diabetes, 
etc.  When  such  a  constitutional  condition  appears  to  be  directly  causative 
of  the  bleeding,  its  correction  or  treatment  becomes  a  sine  qua  non. 

Physical  Measures. —  In  most  forms  of  uterine  hemorrhage,  certain 
simple  mechanical  measures  are  commonly  employed,  and  they  may  be  of 
the  greatest  importance  in  controlling  the  bleeding. 

Rest  in  Bed. —  The  first  essential  in  all  cases  of  severe  uterine  hemor- 
rhage is  to  put  the  patient  to  bed.  Unless  this  is  insisted  upon,  other  meas- 
ures are  apt  to  be  of  no  avail.  In  the  milder  forms  of  menorrhagia  or 
metrorrhagia,  especially  when  the  latter  is  kept  up  for  many  weeks,  it  is  not 
usually  possible  to  keep  the  patient  in  bed  continuously.  The  greater  the 
amount  of  rest  in  the  recumbent  position,  however,  the  less  the  tendency 
to  bleed,  and  the  better  the  chanoe  of  spontaneous  cessation. 

Cold  Applications  to  Abdomen. — •  The  application  of  cold,  usually 
in  the  form  of  the  ice  bag  to  the  lower  abdomen,  is  a  measure  frequently 
resorted  to,  and  one  which  is  of  undoubted  service.  The  good  effect  of 
this  measure  is  no  doubt  dependent  upon  the  contractile  effect  of  the  cold, 
whether  direct  or  indirect,  on  the  uterine  musculature. 

Hot  Vaginal  Douches. —  A  time  honored  method  of  treating  most 
types  of  uterine  bleeding,  especially  metrorrhagia,  is  by  means  of  hot 
vaginal  douches.  To  be  of  any  value,  the  douche  must  be  taken  in  the 
recumbent  position.  Unless  instructed  on  this  point,  women  sometimes 
attempt  douching  in  the  sitting  position,  as  over  a  commode  or  bucket. 
Little  good  can  be  expected  from  a  douche  taken  in  this  way,  as  the  water 
does  not  reach  the  vaginal  fornix,  as  it  should. 

To  the  woman  w^ho  must  employ  douching  the  ordinary  douche  pan  is 
of  the  greatest  service,  though  not  indispensable.  A  less  convenient  though 
serviceable  method  is  for  the  woman  to  lie  across  the  bed,  with  the  hips 
projecting  just  beyond  the  edge  and  the  feet  resting  on  a  chair  placed  close 
to  the  bed.  A  rubber  sheet  or  pad,  or  a  piece  of  oilcloth,  protects  the  bed 
clothing  and  conducts  the  return  flow  to  a  bucket  at  the  side  of  the  bed.  The 
douche  can  or  bag  is  suspended  several  feet  above  the  level  of  the  patient's 
hips.  The  nozzle  is  introduced  for  a  distance  of  about  two  inches  and  the 
solution  then  allowed  to  flow  into  the  vagina.  The  whole  process  is  of 
course  greatly  facilitated  when  the  douche  can  be  given  by  a  nurse  or  attend- 
ant rather  than  by  the  patient  herself,  as  is  sometimes  necessary.  The  foun- 
tain syringe  is  more  satisfactory  than  the  bulb  variety,  which  possesses 
the  further  disadvantage  of  easily  getting  out  of  order. 


254  MENSTRUATION  AND  ITS  DISORDERS 

For  uterine  bleeding  the  douche  may  be  one  of  hot  water  alone,  or  of 
some  such  simple  substance  as  normal  saline,  boric  acid  or  borax  solution. 
The  temperature  of  the  douching  fluid  should  be  as  high  as  can  well  be 
borne  by  the  patient.  Usually  this  will  be  about  iio°  F.,  although  some 
patients  can  endure  a  temperature  of  120°  F.  without  much  discomfort. 
The  amount  should  never  be  less  than  one  gallon,  and  a  larger  douche  is 
often  desirable.  The  frequency  with  which  the  treatment  should  be  given 
varies  according  to  circumstances.  In  hemorrhage  of  moderate  degree, 
twice  a  day  is  a  good  average,  but  when  more  persistent  or  abundant,  the 
douche  should  be  given  at  least  three  times  each  day. 

Vaginal  Tampons. —  In  cases  of  severe  uterine  hemorrhage,  it  is  occa- 
sionally necessary  to  insert  some  form  or  other  of  vaginal  tampon,  usually 
in  the  form  of  long  strips  of  sterilized  gauze.  As  a  rule  this  means  of  con- 
trolling hemorrhage  is  used  only  as  a  temporizing  measure,  pending  more 
active  treatment,  such  as  curettage.  This  applies  especially  to  the  profuse 
hemorrhage  sometimes  seen  in  cases  of  incomplete  abortion.  A  firm  vaginal 
tampon,  consisting  perhaps  of  several  yards  of  gauze  packed  tightly  against 
the  vaginal  fornix,  is  often  of  the  greatest  service.  Its  value  depends  not 
only  on  the  direct  pressure  w^hich  it  exerts,  but  also  on  the  fact  that  it 
excites  uterine  contraction,  thus  tending  to  cause  cessation  of  the  bleeding  as 
well  as  expulsion  of  the  residual  gestation  products.  In  this  way  instru- 
mental or  digital  emptying  of  the  uterus  is  often  made  unnecessary.  A 
vaginal  pack  is  also  occasionally  called  for  in  the  control  of  hemorrhage 
due  to  other  causes,  such  as  cancer  or  myoma  of  the  uterus,  hyperplasia  of 
the  endometrium,  uterine  polypi,  etc. 

Treatment  by  Drugs. —  The  number  of  drugs  v^hich  have  been  em- 
ployed in  the  treatment  of  both  menorrhagia  and  metrorrhagia  is  legion. 
The  emplo}Tnent  of  only  a  few,  however,  has  been  based  on  any  principle 
of  rational  therapy,  and  some  have  little  to  commend  them  except  the  claims 
of  their  manufacturers. 

Ergot. —  Ergot  has  always  been  looked  upon  as  the  sheet  anchor  in  the 
treatment  of  uterine  hemorrhage.  AVhen  its  use  is  dictated  by  pharmaco- 
dynamic considerations,  the  results  obtained  are  often  very  gratifying. 
The  principal  indication  for  the  exhibition  of  ergot  is  bleeding  of  the  atonic 
type,  seen  most  characteristically  post  partum  or  post  abortum.  The  direct 
stimulating  effect  of  ergot  upon  the  involuntary  muscle  of  the  uterus 
causes  a  powerful  tonic  contraction.  No  more  effective  means  of  hemo- 
stasis  could  be  secured,  and  in  the  great  majority  of  cases  the  bleeding  is 
controlled. 

The  cases  in  which  ergot  rarely  yields  results  are  those  in  which  the 
uterine  muscle  is  not  at  fault.  These  embrace,  of  course,  the  largest 
number  of  cases  encountered  in  gynecological  practice.  It  seems  unrea- 
sonable to  expect  much  assistance  from  ergot  where  the  hemorrhage  is 
due  to  some  definite  pelvic  lesion,  such  as  uterine  or  ovarian  tumors, 
adnexitis,  etc.     And  yet  it  is  frequently  given  to  patients  of  this  group. 


UTERINE  HEMORRHAGE  255 

Again,  in  functional  hemorrhage,  such  as  that  seen  at  puberty  or  at  the 
menopause,  the  use  of  ergot  can  scarcely  be  of  much  avail,  for  here  the  defect 
lies  in  the  endocrine  system.  The  point  to  be  emphasized  regarding  the 
administration  of  ergot,  therefore,  is  that  its  use  should  be  confined  to 
those  cases  in  which  there  is  reason  for  believing  that  atony  of  the  uterine 
musculature  plays  an  etiological  role. 

Ergot  is  most  commonly  administered  in  the  form  of  the  fluidextract. 
When  a  pronounced  effect  is  desired,  as  for  example  in  the  prophylaxis  of 
postpartum  hemorrhage,  the  dose  should  be  one  dram.  When  its  use  is  to 
be  continued  over  a  longer  period,  as  in  the  treatment  of  moderate  uterine 
bleeding,  smaller  doses  are  to  be  employed.  In  cases  of  this  type  I  am  in 
the  habit  oi  prescribing  about  twenty  minims  of  the  fluidextract  every  four 
hours.  For  hypodermatic  administration,  when  called  for  by  such  emer- 
gencies as  the  occurrence  of  postpartum  hemorrhage,  either  the  official 
fluidextract  or  one  of  the  proprietary  forms  of  the  drug  may  be  employed 
hypodermically  (ergotol,  ernutin,  etc.).  The  latter  have  come  into  exten- 
sive use  for  internal  administration  also. 

Hydrastis. —  Hydrastis,  in  the  form  of  hydrastinin,  is  one  of  the  most 
popular  drugs  used  in  the  treatment  of  uterine  hemorrhage.  Its  stimulating 
effect  on  the  uterus  is  much  greater  than  that  of  hydrastis,  from  which 
it  is  derived.  Unlike  ergot,  it  does  not  cause  contraction  of  the  uterine 
muscle,  its  value  as  a  hemostatic  depending  upon  its  constricting  effect  upon 
the  arterioles.  Hydrastinin  may  be  given  in  average  doses  of  about  one 
half  grain  of  the  hydrochlorid.  When  the  fluidextract  of  hydrastis  is 
employed,  the  dose  should  be  about  30  minims. 

CoTARNiN  Phthalate. —  A  drug  which  has  attained  considerable  vogue 
in  Europe,  and  to  a  less  extent  in  this  country,  is  cotarnin  phthalate,  or 
styptol.  It  is  an  oxidation  derivative  of  the  opium  alkaloid  narcotin.  Like 
hydrastis,  it  produces  a  pronounced  ateriolar  constriction.  Its  advantage 
over  the  latter  drug,  however,  lies  in  the  fact  that  its  action  is  confined  to 
the  urogenital  system.  It  is  therefore  much  safer  than  hydrastis,  which 
may  bring  about  a  dangerous  increase  in  blood  pressure.  The  average  dose 
is  about  three  quarters  of  a  grain  every  4  hours. 

Other  Drugs  for  Internal  Administration. —  Other  drugs  which  have 
been  employed  in  the  treatment  of  either  menorrhagia  or  metrorrhagia  are 
apiol,  gossypium,  cannabis  indica,  gallic  acid,  calcium  salts,  digitalis,  etc. 

Intra-Uterine  Applications  of  Drugs. —  While  there  are  both  theo- 
retical and  practical  objections  to  the  treatment  of  uterine  hemorrhage  by 
intra-uterine  applications,  this  method  is  still  warmly  commended  by  some 
gynecologists.  Boldt,  for  example,  advises  the  use  of  zinc  chlorid  in  this 
manner.  He  recommends  that  the  application  be  made  of  longer  duration 
by  leaving  within  the  uterus  a  gauze  strip  saturated  with  the  medicament. 
From  five  to  ten  drops  of  a  50  per  cent  solution  of  zinc  chlorid,  or  a  some- 
what larger  amount  of  a  10  to  20  per  cent  solution,  may  be  applied.  A 
special  "  applicator  syringe  "  is  used  to  make  the  application.     The  gauze 


256  MENSTRUATION  AND  ITS  DISORDERS 

is  left  in  about  three  days.  Instead  of  zinc  chlorid,  pure  phenol  or  phenol 
diluted  with  glycerin  may  be  used.  In  the  latter  case,  the  gauze  should  be 
withdrawn  after  a  few  hours. 

Gerstenberg  advocates  the  application  of  pure  formalin  to  the  endo- 
metrium in  cases  of  uterine  hemorrhage,  especially  of  the  climateric 
variety. 

Injections  of  Blood  and  Serum. —  Curtis  calls  attention  to  the  efficacy 
of  injections  of  whole  blood  in  uterine  hemorrhage.  The  following  very 
simple  technic  is  recommended  :  "A  20  c.cm.  or  larger  ground  glass  syringe 
is  sterilized,  preferably  by  the  drug  method,  and  the  inner  surface  lubri- 
cated with  sterile  petrolatum.  Blood  is  withdrawn  in  the  usual  manner 
from  a  cubital  vein  of  the  donor;  the  needle  is  then  inserted  beneath  the 
subcutaneous  tissues  of  the  back  of  the  patient  and  the  blood  injected." 
The  injections  may  be  repeated  when  necessary. 

Instead  of  whole  blood,  the  use  of  human  serum  has  been  advised  by 
Thwaite,  while  Kaiser  advocates  the  use  of  horse  serum.  The  last  named 
is  certainly  the  most  convenient  form  of  medication,  for  the  horse  serum  is 
easily  obtainable  commercially.  Finally,  mention  may  be  made  of  the 
injection  of  coagulen  (New  and  Non-Official  Remedies,  A.M.A.),  a. pro- 
prietary which  is  said  to  hasten  coagulation.  The  results  in  the  few  cases 
in  which  I  have  employed  it  have  been  encouraging. 

Organotherapy. —  See  Chapter  XXVI. 

Treatment  by  Radium  and  X-Ray. —  See  Chapter  XXVII. 

Treatment  of  Functional  Uterine  Hemorrhage. —  Among  the  most 
interesting,  and  also  the  most  perplexing,  problems  encountered  in  gyneco- 
logical practice  is  the  treatment  of  cases  of  "  functional,"  or  "  idiopathic," 
or  "  essential  "  uterine  bleeding.  This  type,  as  has  been  stated  elsewhere 
in  this  chapter,  includes  the  numerous  cases  O'f  functional  climacteric  hemor- 
rhage and  the  less  frequent  instances  of  menorrhagia  of  puberty.  In  the 
majority  of  such  cases,  especially  if  severe,  curettage  is  indicated,  chiefly 
for  diagnostic  purposes.  In  the  case  of  menopausal  hemorrhage,  the  indi- 
cation for  curettage  is  urgent,  on  account  of  the  importance  of  excluding 
carcinoma.  The  most  common  histological  finding,  with  genuine  functional 
bleeding,  is  hyperplasia  of  the  endometrium. 

Curettage  in  itself  is  rarely  successful  in  relieving  this  form  of  uterine 
hemorrhage.  Many  gynecologists  advocate  a  repetition  of  the  procedure 
on  the  recurrence  of  the  bleeding,  and  not  infrequently  patients  are  sub- 
mitted to  curettage  many  times.  Although  cures  are  sometimes  obtained, 
curettage  can  scarcely  be  looked  upon  as  a  rational  form  of  therapy  in  these 
cases,  inasmuch  as  it  merely  removes  a  manifestation  or  end  product  of  the 
underlying  cause,  which  is  an  endocrine  disorder  involving  the  ovary. 

The  logical  treatment  of  these  cases  would  seem  to  be  along  the  lines  of 
organotherapy,  but  unfortunately  the  results  of  this  form  of  treatment  are 
still  far  from  satisfactory.  For  a  discussion  of  this  subject  see  Chapter 
XXVI. 


UTERINE  HEMORRHAGE  257 

Patients  with  intractable  functional  hemorrhage  are  often  benefited  by 
the  proper  administration  of  radium  or  the  X-ray  (see  Chapter  XXVII). 
In  the  case  of  women  at  or  near  the  menopause  it  is  possible,  and  usually 
advisable,  to  bring  about  a  complete  cessation  of  the  menstrual  function. 
The  problem  is  more  difficult  in  the  case  of  younger  women  in  the  child 
bearing  age.  Still,  even  here,  the  expert  use  of  radium  or  the  X-ray  may 
result  in  diminution  of  the  flow  without  actual  cessation.  The  latter 
eventuality,  however,  is  one  of  the  risks  of  this  form  of  treatment. 

Finally,  there  are  still  many  gynecologists  who,  in  the  case  of  severe  and 
intractable  uterine  hemorrhage  of  this  type,  prefer  to  perform  a  hysterec- 
tomy. Fortunately,  this  is  usually  a  simple  and  relatively  safe  procedure 
in  cases  of  this  group.  It  should,  however,  be  looked  upon  as  a  dernier 
resort,  its  employment  being  dependent  upon  the  consideration  of  such  indi- 
vidual factors  as  the  age  of  the  patient,  her  social  status,  the  number  cf 
children  and  the  possible  desire  for  further  pregnancies,  the  duration  and 
severity  of  the  bleeding,  etc. 

XXII 

LITERATURE 

Aarons.     Medical  Treatment  of  Uterine  Hemorrhage.     Medical   Press  and 

Circ,  1906,  82,  553. 
Abler.     Zur  Physiologie  und  Pathologie  des  Ovarialfunktion.     Arch  f.  Gyn., 

1912,  95.  349- 
Ahreiner.     Ueber  die  Blutungen  bei  den  Sogenannten  Chronischen  Metritis. 

Arch.  f.  Gyn.,  1908,  85,  372. 
Albrecht.     Die  Pathologische  Anatomie  der  Endometritis.     Monats.  f.  Geb. 

u.  Gyn.,  191 1,  34,  397. 
Anspach.     Hemorrhagia  Uteri:  Myopathic  Uterine  Hemorrhage.     Tr.  Am. 

Gyn.  See,  1909,  34,  800. 
BoLDT.     Zinc  Chloride  in  Treatment  of  Uterine  Hemorrhage.     Jour.  A.  M.  A., 

1917,  68,  832. 
BuKOjEMSKY.     Die  Gebarmuttersklerose  und  deren  Zusammenhang  mit  den 

Uterusblutungen.     Arch.  f.  Gyn.,  1913,  99,  463. 
BussE.     Die  Behandlung  von  Gebarmutterblutungen  mit  Serum.     Zentralbl.  f. 

Gyn.,  1908,  33,  236. 
BiJTTNER.     Zur  Endometritisfrage.    Gyn.  Rundsch.,  1909,  3,  508. 
Chalfant.    Arteriosclerosis  of  the  Uterine  Vessels.     Jour.  A.  M.  A.,  191 1, 

56,  239. 
CuLLEN.     Cancer  of  the  Uterus.     1900. 

Also  Adenomyoma  of  the  uterus.     1908. 
Dalche.     Chlorose  menorrhagique  :  metrorrhagies  virginales ;  irrigation  d'  eau 

procede.     Rev.  Mens,  de  Gynec,  d'Obstet,  et  de  Pediait.     Par.  1909,  4, 

185. 
Driessen.     Endometritis,  Folge  Abnormaler  Menstruation,  Ursache  Profuser 
Blutungen.     Zentralbl.  f.  Gyn.,  1914,  38,  618, 


258-  MENSTRUATION  AND  ITS  DISORDERS 

Ehrenfest.  Influence  of  Central  Nervous  System  in  the  Causation  of 
Uterine  Hemorrhages.     Amer.  J.  Obst.,  1908,  57,  161. 

Eppinger  and  Hess.  Zur  Paithologie  des  Vegetativen  Nervensystems. 
Zeitsch.  f.  Khn.  Med.,  1909,  67,  345. 

FiNDLEY.  Uterine  Hemorrhage.  (Collective  review).  Internat.  Abst.  of 
Surg.,  1916.     (March). 

Arteriosclerosis  of  the  Uterus  as  a  Causal  Factor  in  Uterine  Hemor- 
rhage.    Tr.  Amer.  Gyn.  Soc,  1905,  30,  399. 

FuTH.     Ueber  die  Behandlung  Uncomplicierter  Blutungen,  etc.    Arch.  f.  Gyn., 

1910,  92,  72. 

Gardner  and  Goodall.     Chronic  Metritis  and  Arteriosclerotic  Uterus.     Brit. 

Med.  J.,  1906,  2,  1 1 76. 
Geist.     Essential  Uterine  Hemorrhage.     Surg.  Gyn.  and  Obst.,  1915,  21,  454. 
Gellhorn  and  Ehrenfest.     Syphilis  of  Internal  Genital  Organs  of  Female. 

Tr.  Amer.  Gyn.  Soc,  1916,  41,  129. 
Goodall.     Climacteric  Hemorrhage.     Am.  J.  Obst.,  1910,  61,  32. 
■ The  Involution  of  the  Puerperal  Uterus,  with  Special  Reference  to  the 

Involution  of  its  Circulatory  System.     Amer.  J.  Obst.,  1909,  60,  921. 
Goth.     Endometritis  Hemorrhagica.     Monats.  f.  Geburts.  und  Gyn.,  1906,  23, 

632. 
Handford.     Menstruation  and  Phthisis.     Brit.  M.  J.,  1887,  i,  153. 
Hartje.     Zur  Lehre  von  den  Hyperplastichen  Veranderungen  des  Uterus- 

schleimhaut.     Zentralb.  f.  Gyn.,  1907,  31,  1465. 
Henkel.     Klinische  und  Anatomische  Untersuchungen  iiber  die  Endometritis. 

Zentralb.  f.  Gyn.,  1909,  33,  201. 

Ueber  die  Wechselbeziehung  zwischen  Uterus  und  Ovarien,  ein  Beitrag 

zur  Behandlung  Gynakologischer  Blutungen.     Miinch.  Med.  Wchnsch., 

191 1,  58,  337. 

Himmelheber.  Zur  Bedeutung  der  Glandularen  Hyperplasie  und  Hyper- 
trophie  des  Endometriums.     Monats.  f.  Geb.  u.  Gyn.,  1895,  30,  159. 

HiRSH.  Zur  Lehre  von  der  Atiologie  und  Therapie  der  Uterusblutungen. 
Monats.  f.  Geb.  u.  Gyn.,  1913,  37,  420. 

Hitschmann  and  Adler.  Der  Bau  der  Uterusschleimhaut,  etc.,  Monats.  f. 
Geb.  u.  Gyn.,  1908,  27,  i. 

Ein  Weiterer  Beitrag  zur  Kenntnis  der  Normalen  und  Entziindeten 

Uterusmucosa.    Arch.  f.  Gyn.,  1913,  ipo,  233.- 

Kaji.     Zur   Ovariellen   Atiologie  Uteriner  Blutungen.      Monats,    f.   Geb.   u. 

Gyn.,  1910,  32,  427. 
Kelly  and  Cullen.     Myoma  of  the  Uterus.     1909. 
Kronig.     Einige    Moderne    Behandlungsmethoden    der    Blutungen    in    der 

Geburtshilfe  und  Gynakologie.     Therap.  d.  Gegenw.,  191 1,  52,  24. 
Krusen.     Surgical  Treatment  of  Uterine  Hemorrhage  from  the  Nonpregnant 

Uterus.     Amer.  J.  Obst.,  1913,  67,  885. 
KuBO.     Menorrhagia  and  Metrorrhagia.     Amer.  J.  Obst.,  1908,  57,  675. 
Lauth.     Ueber  das  Verhalten  des  Uterus  bei  Ovarialblutungen.     Monats.  f. 

Geb.  u.  Gyn.,  191 5,  42,  36. 
Lehman.     Klimakterische  Blutungen,  etc.     Zentral.  f.  Gyn.  1913,  37,  96. 
Leicester.     Case   of   Very    Severe    Menorrhagia    Associated    with    Chronic 

Nephritis.     J.  Obst.  and  Gyn.,  Brit  Emp.,  1908,  14,  269. 


UTERINE  HEMORRHAGE  259 

Lewers.  Two  Cases  of  Metrorrhagia  at  an  Advanced  Age  not  Due  to  Malig- 
nant Disease.     Lancet,  1909,  i,  1169. 

Macdonald.  Intractable  Uterine  Hemorrhage  and  Arteriosclerosis  of 
Uterine  Vessels.     J.  Obst.  and  Gyn.,  Brit.  Emp.,  1907,  11,  152. 

Maier.  Cotarnine  Phthalate  in  Uterine  Hemorrhage.  Amer.  J.  Obst.,  1907, 
56,  820. 

Mallett.  Uncontrollable  Hemorrhage  from  the  Nonpuerperal  Uterus.  Amer. 
J.  Obst.,  1909,  60,  480. 

Marbe.  Le  principe  de  I'hyperovaricme  menstruel,  etc.  Compt.  Rend.  Soc, 
de  Biol.,  Par.,  1908,  64,  85. 

Muratow.     Metrorrhagia  Syphilitica.     Zentralb.  f.  Gyn.,  1907,  31,  830. 

NoRRis  A  Variety  of  Chronic  Endometritis  Characterized  Clinically  by  Pro- 
fuse Hemorrhages.     Amer.  J.  Obst.,  1909,  59,  399. 

Novak.  Pathologic  Physiology  of  Uterine  Bleeding.  Jour.  A.  M.  A.,  1914, 
63,  617. 

Hyperplasia  of  the  Endometrium.     Amer.  J.  Obst.,  191 7,  75,  996. 

Novak.     Relation  of   Hyperplasia  of  Endometrium  to   so-called   Functional 

Uterine  Hemorrhage.     Jour.  A.  M.  A.,  1920,  75,  292. 
Outerbridge.     Hemorrhage    from    Non-pregnant    Uterus.     Amer.    J.    Obst., 

1913,  67,  971. 
Pankov/.     Ueber  die  Ovarielle  Ursache  Uteriner  Blutungen.    Monats.  f.  Geb. 

u.  Gyn.,  191 1,  30,  339. 

Die  Ursachen  der  Uterusblutungen.     Miinch.  Med.  Wchnsch.,  1909,  56, 

2701. 

• •     Die  Metropathia  Hemorrhagica ;  etc.    Ztschr.  f .  Geb.  u.  Gyn.,  1909,  65, 

336. 
PoLZL.     Ueber  Menstrueller  Veranderungen  des  Blutbefindes.     Wien.  Klin. 

Wchnsch.,  19 10,  23,  238. 
Rees.     Arteriosclerosis  of  Uterus.     Amer.  J.  Obst,  1908,  58,  748. 
Reinecke.     Die  Sklerose  der  Uterinarterien.     Arch.  f.  Gyn.,  1897,  53,  340. 
Rieck.     Zur  Therapie  Ubermassig  Starker  Menstrueller  Blutungen.     Deutsche 

Med.  Wchnsch.,  1913,  39,  653. 
Sampson.     Blood  Supply  of  Uterine  Myomata.     Amer.  J.  Obst.,  191 1,  64,  294. 
Schickele.     Wirksame  Substanzen  in  Uterus  und  Ovarium.     Miinch.  Med. 

Wchnsch.,  191 1,  58,  123. 

UND  Keller.     Die  Glandulare  Hyperplasie  der  Uterusschleimhaut,  etc. 

Arch.  f.  Gynak,  1912,  95,  586. 

ScHiFFMAN.  tJber  Ovarialveranderungen  nach  Radium  und  Mesothorium- 
bestrahlung.     Zentralb.  f.  Gyn.,  1914,  38,  760. 

Schroder.  Anatomische  Studien  zur  Normalen  und  Pathologischen  Physiolo- 
gic des  Menstruationszyklus.     Arch.  f.  Gyn.,  1915,  104,  27. 

Sehrt.  Zur  Thyreogenen  Atiologie  der  Hamorrhagischen  Metropathien 
Miinch.  Med.  Wchnsch.,  191 3,  60,  961. 

Seitz  und  Wintz.  Ueber  die  Besei/tigung  von  Myomawechselblutungen,  etc. 
Miinch.  Med.  Wchnsch.,  1916,  63,  1785. 

Siredey  et  Lemaire.  Les  metrorrhagies  virginales,  etc.  Ann.  de  Gynec.  et 
d'Obst.,  Par.,  1910,  7,  665. 

Slocum.     Arteriosclerosis  of  the  Uterus.     Surg.  Gyn.  and  Obst.,  1908,  6,  32. 


260  MENSTRUATION  AND  ITS  DISORDERS 

SoLOWij.     Die  Sklerose  der  Arterien  der  Gebarmutter  als  Ursache  von  Un- 

stillbaren  Blutungen.     Monats.  f.  Geb.  u.  Gyn.,  1907,  25,  291. 
Sturmdorf.     Metrorrhagia  and  Uterine  Fibrosis.     Amer.  J.  Obst,  1910,  61, 


Theilhaber.  Insufficiemtia  Uteri ;  Atonia  Uteri ;  Hyperplasia  Uteri  und 
Uterusblutungen.     Monats.  f.  Geb.  u.  Gyn.,  1910,  31,  727. 

Wanner.  Zur  Behandlung  der  Klimakterischen  und  Praklimakterischen 
Blutungen  und  Hypersekretionen.  Monats.  f,  Geb.  u.  Gyn.,  1912,  36, 
301. 

Watkins.     Arteriosclerosis  of  Uterus.    Surg.  Gyn.  and  Obst.,  1907,  5,  603. 

Weil.  Les  menorrhagies  de  la  puberte.  Ann.  de  Med.  et  Chir.  Inf.,  Par., 
1912,  16,  553. 

Le  traitement  des  hemorragies  genitales  de  la  femme  par  les  serums 

sanguins.     Gynecologie,  Par.,  1913,  17,  257. 

Whitehouse.  Pathology  and  Treatment  of  Uterine  Hemorrhage.  Practi- 
tioner, 191 3,  90,  952. 

Willey.  Menstruation  and  Menorrhagia.  J.  Obst.  and  Gyn.,  Brit.  Emp., 
1909,  15,  236. 

WiTTEK.     Sklerotic  Blood  Vessel  Changes  in  Nullipara  and  Multipara,  and 
Climacteric  Bleeding.     Monats.  f.  Geb.  u.  Gyn.,  1906,  33,  796. 
•      Wood.     Drug  Treatment  of  Uterine  Hemorrhages.     Amer.  J.  Obst,  1913,  67, 

875- 


CHAPTER  XXIII 

VICARIOUS   MENSTRUATION 

Definition  and  Varieties. —  The  term  vicarious  menstruation  is  ap- 
plied to  certain  rather  rare  cases  in  which  extragenital  hemorrhage,  from 
one  part  of  the  body  or  another,  occurs  at  regular  intervals,  corresponding 
to  the  menstrual  periods.  In  some  cases  the  extragenital  hemorrhage 
appears  to  take  the  place  of  the  normal  uterine  menstrual  bleeding,  which 
is  altogether  absent.  These  are  the  cases  of  the  so-called  substitutional 
type.  In  other  instances  menstruation  occurs  "  per  vias  naturales,"  but  some 
form  of  extragenital  bleeding  is  noted  in  addition.  To  this  type  the 
name  of  supplementary  menstrual  hemorrhage  is  applied. 

A  good  deal  of  fault  has  been  found  with  the  term  vicarious  menstruation. 
There  is  no  certainty,  it  is  stated,  that  the  abnormal  extragenital  hemor- 
rhage is  really  in  the  nature  of  a  menstrual  discharge,  and  hence  it  would 
seem  that  it  might  more  justifiably  be  spoken  of  as  a  vicarious  hemorrhage 
than  as  a  vicarious  menstruation.  In  the  second  place,  as  has  already  been 
stated,  the  hemorrhage  is  not  always  strictly  vicarious,  i.  e.,  substitutional, 
for  at  times  the  normal  menstrual  flow  occurs  synchronously  with  it. 
In  spite  of  these  justifiable  objections,  however,  the  term  vicarious  men- 
struation has  come  into  such  general  vogue  that  it  will  be  difficult  to  dis- 
place it. 

Incidence. —  Vicarious  menstruation  must  be  looked  upon  as  a  rela- 
tively rare  phenomenon.  Indeed,  a  strong  tendency  has  always  been 
evident  to  doubt  its  existence.  No  less  a  personage  than  Matthews  Duncan 
stated,  as  late  as  1884,  that  he  had  never  observed  an  instance  of  this  dis- 
order. He  said,  further  "It  is  high  time  to  give  up  the  whole  disease  as 
a  tissue  of  error  if  not  of  absurdity."  Authentic  reports  of  vicarious  men- 
struation are  now  so  numerous  that  there  can  be  no  question  as  to  its  occur- 
rence. It  must  still,  however,  be  regarded  as  a  very  uncommon  phenomenon. 
There  can  be  no  doubt  that  a  very  large  proportion  of  cases  which  have 
been  reported  as  vicarious  menstruation  represent  errors  in  diagnosis,  as 
will  be  emiphasized  later.  The  statement  credited  to  Lawson  Tait  is  apropos 
in  this  connection,  "  I  do  not  absolutely  deny  that  there  is  any  such  thing 
as  vicarious  menstruation,  but  I  do  deny  the  propriety  of  examiners  at  the 
University  of  London  or  anywhere  else  asking  the  commonest  cause  of 
epistaxis  and  receiving  the  answer  of  vicarious  menstruation  with  approval," 
Roth  has  found  225  cases  recorded  since  1870, 

Sources  of  Hemorrhage. —  The  Nasal  Mucous  Membrane. —  Most 
frequently  vicarious  menstruation  occurs  in  the  form  of  epistaxis.     The 

261 


262  MENSTRUATION  AND  ITS  DISORDERS 

hemorrhage  may  be  slight,  but  is  often  rather  profuse,  continuing  inter- 
mittently throughout  the  normal  menstrual  period.  In  rare  instances  it 
may  be  alarming.  No  satisfactory  explanation  has  been  offered  as  to  the 
frequency  with  which  the  nasal  mucosa  gives  rise  to  this  form  of  hemor- 
rhage. The  question  would  seem  to  be  closely  related  to  that  of  the 
occurrence  of  so-called  nasal  dysmenorrhea  (see  Chapter  XX).  The  ex- 
planation of  both  these  disorders  appears  to  presuppose  a  histological  rela- 
tionship between  the  generative  apparatus  and  the  nose,  and  there  is,  indeed, 
some  evidence  for  such  a  view.  Cases  of  nasal  vicarious  menstruation  have 
been  reported  by  numerous  observers  (Walker,  Coughlin,  Macht). 

The  Stomach. —  Next  to  the  nasal  tract,  the  stomach  is  perhaps  the 
most  frequent  source  of  vicarious  menstrual  hemorrhage.  In  most  cases 
the  hemorrhage  is  slight  in  amount,  and  therefore  not  attended  with  danger 
to  life.  The  long  intermenstrual  interval  between  the  hemorrhages,  fur- 
thermore, gives  the  patient  an  opportunity  to  recuperate  from  their  effects. 
In  the  slighter  grades  of  hemorrhage,  there  are  often  no  associated  symp- 
toms whatsoever.  Kuttner,  for  example,  mentions  a  patient  who  was  taken 
with  such  a  hemorrhage  while  dining  in  a  restaurant.  Although  a  cupful 
of  blood  was  vomited,  the  patient  complacently  finished  her  meal  without 
further  disturbance. 

In  the  more  severe  forms  the  loss  of  blood  may  cause  anemia,  vertigo, 
weakness,  and  nausea.  According  to  Kuttner,  vicarious  hemorrhages  from 
the  stomach  are  often  preceded  by  bloody  stools.  Sometimes;  the  hemor- 
rhage occurs  only  once  at  the  menstrual  period ;  in  other  cases  the  vomiting 
of  blood  may  be  repeated  many  times.  Darnall's  patient,  for  example,  is 
said  to  have  had  nine  hemorrhages  in  one  day. 

Exceeding  caution  should  be  exercised  in  concluding  that  gastric  hemor- 
rhage in  a  given  case  is  the  result  of  a  vicarious  menstruation,  on  account 
of  the  much  greater  probability  of  its  being  due  to  actual  stomach  disease, 
especially  ulcer.     This  subject  will  be  discussed  in  another  paragraph. 

The  Intestinal  Canal. —  While  vicarious  menstruation  from  this 
source  is  less  frequently  observed  than  that  from  the  stomach,  it  occurs 
occasionally.  Since  slight  or  moderate  intestinal  hemorrhage  is  more 
easily  overlooked  than  the  vomiting  of  blood,  it  is  probable  that  intestinal 
bleeding  is  not  quite  so  rare  as  has  been  believed.  Usually  it  is  slight, 
being  characterized  by  bloody  stools  during  menstruation.  On  the  other 
hand,  one  of  the  few  fatal  cases  of  vicarious  menstruation  which  I  have 
found  recorded,  that  of  Holmes,  is  said  to  have  been  of  the  intestinal  type. 

The  Lungs. —  Hemoptysis  as  a  manifestation  of  vicarious  hemorrhage 
has  been  described  by  many  authors,  but  in  a  great  many  of  the  published 
reports  it  does  not  seem  to  have  been  conclusively  established  that  tubercu- 
losis was  not  the  causative  factor  in  the  hemorrhage.  On  the  other  hand, 
it  must  be  admitted  that  hemorrhage  occurring  only  at  the  menstrual 
periods,  whether  of  tuberculous  origin  or  not,  is  still  within  the  scope  of 
application  of  the  term  vicarious  menstruation.     Ford's  case  is   a  good 


VICARIOUS  MENSTRUATION  263 

example  of  this  form  of  vicarious  menstruation.  His  patient  was  a  woman 
of  25,  who  had  commenced  to  menstruate  at  15.  The  periods  were  normal 
until  the  age  of  19,  when  the  patient  is  said  to  have  "  caught  cold  "  during 
menstruation.  After  that  there  was  only  an  occasional  "  show  "  of  men- 
strual discharge,  but  at  regular  intervals  of  twenty-six  days  there  was  a 
pulmonary  hemorrhage  lasting  from  three  to  four  days.  Repeated  lung 
examinations  were  negative.  This  subject  is  further  discussed  in  Chapter 
XXV. 

The  Mammary  Glands. —  In  view  of  the  very  close  physiological  rela- 
tion between  the  female  generative  organs  and  the  mammary  glands,  it  is 
not  surprising  that  the  latter  may  be  the  seat  of  vicarious  menstrual  phe- 
nomena. Abnormal  lactation  at  the  time  of  menstruation  has  been 
described  in  a  large  number  of  cases,  in  virgins  as  well  as  in  parous  women. 
In  the  broadest  sense  such  an  occurrence  may  perhaps  be  considered  a 
vicarious  menstrual  phenomenon. 

More  striking  are  the  cases  in  which  there  is  an  actual  discharge  of  blood 
from  the  nipple  at  each  menstrual  period.  I  have  recently  observed  such 
an  occurrence  in  a  colored  woman  of  44,  who  was  passing  through  the 
menopause.  Each  month  there  was  a  slight  serosanguinolent  discharge 
from  both  nipples,  as  I  was  able  to  demonstrate  for  myself  over  a  period  of 
several  months.  Many  of  the  other  reported  cases  were  likewise  observed 
at  or  near  the  menopause.  Thornton's  patient,  on  the  other  hand,  was  a 
virgin  of  32,  who  found  it  necessary  to  keep  a  cotton  tampon  over  each 
breast  during  the  menstrual  period.  The  bloody  discharge  from  one  of  the 
breasts  was  so  free  that  the  tampon  had  to  be  changed  once  each  day. 
More  or  less  similar  cases  are  reported  by  Hirschberg,  Ziegenspeck, 
Lambinon,  and  others. 

An  unusual  form  of  mammary  participation  in  the  menstrual  process  is 
exemplified  by  the  case  of  Condit.  In  this  the  gland  became  swollen  to 
twice  its  normal  size,  and  "  presented  a  very  alarming  picture  as  the  skin 
became  so  generally  ecchymotic  as  to  present  a  complete  blue  black  mamma." 
The  curious  feature  of  this  case  is  that  no  discharge  of  any  kind  appeared 
at  the  nipple. 

The  Skin. —  Bleeding  from  the  skin,  as  a  manifestation  of  vicarious 
menstruation,  is  an  exceedingly  rare  phenomenon,  although  cases  have  been 
reported  by  Parrot,  Miiller,  and  others.  In  a  number  of  these  cases,  such 
as  those  reported  by  Chambers  and  Anderson,  the  bleeding  was  preceded 
by  erythema  of  the  skin.  From  the  area  of  the  eruption  there  issued  a  sero- 
sanguinous  fluid  and  later  pure  blood.  The  so-called  "  bloody  sweat,"  a 
medical  curio'sity,  said  to  have  been  first  described  by  Aristotle,  has  beeii 
observed  in  a  small  number  of  apparently  authentic  cases.  Opel  quotes 
Collard's  case  of  a  Norwegian  girl  of  15,  whose  body,  during  her  first 
menstrual  period,  was  covered  with  red  purpuric  spots.  After  the  admin- 
istration of  sudorifics,  a  bloody  sweat  appeared,  the  process  being  repeated 
several  consecutive  months.     When  pregnancy  supervened,  the  sweating 


264  MENSTRUATION  AND  ITS  DISORDERS 

ceased.  As  possibly  throwing  some  light  on  the  causation  of  the  "  bloody 
sweat,''  or  "  hematidrosis,"  it  is  significant  that  practically  all  the  reported 
cases  have  been  in  markedly  hysterical  individuals  (see  Chapter  XXV). 

A  different  type  of  skin  hemorrhage,  of  apparently  vicarious  origin,  was 
observed  in  Condit's  case,  in  which  the  menstrual  periods  were  accompanied 
by  extensive  subcutaneous  hemorrhages  on  the  extensor  surfaces  of  both 
legs. 

The  Lips. —  The  first  case  of  vicarious  menstruation  from  the  mucous 
membrane  of  the  lips  was  reported  in  1909  by  Hauptmann.  In  his  case 
the  bleeding  came  from  the  lower  lip.  Since  Hauptmann's  report,  similar 
cases  have  been  described  by  Coughlin  and  others. 

The  Eye  and  Eyelids. —  Hemorrhage  into  the  retina  occurring  with 
each  menstrual  period  has  been  noted  by  Huizinga,  Powell,  and  others. 
Huizinga's  patient  was  a  girl  of  17,  who,  following  an  attack  of  dizziness 
and  faintness,  suffered  with  rapidly  developing  dimness  and  distortion  of 
vision,  first  in  the  left  eye,  followed  in  a  few  minutes  by  a  similar  condition 
of  the  right.  On  examination  the  appearance  of  the  fundus  was  that  of 
hemorrhagic  retinitis,  with  numerous  blood  spots  scattered  over  the  field. 
The  condition  cleared  up  after  menstruation,  only  to  return  at  two  succeed- 
ing periods  during  which  she  was  watched. 

A  case  of  vicarious  menstruation  from  the  lower  eyelids  has  been  reported 
by  Claiborne. 

Nevi. —  A  good  example  of  vicarious  hemorrhage  from  this  source  is 
furnished  by  the  case  of  Condit.  Fifteen  days  after  operation  for  removal 
of  the  uterus  and  adnexa,  the  patient  suffered  the  usual  subjective  symp- 
toms of  menstruation,  while  at  the  same  time  there  was  a  hemorrhage  into 
a  nevus,  the  size  of  a  split  pea,  which  was  situated  over  the  left  ninth  inter- 
costal space.  As  a  result  of  the  hemorrhage  the  little  tumor  became  as  large 
as  a  hen's  egg,  but  in  about  4  days,  it  diminished  again  by  one  half.  This 
process  was  repeated  every  twenty-eight  to  thirty-four  days  for  twenty-one 
successive  months.  There  was  never  any  hemorrhage  from  the  tumor 
until  about  twenty-one  months  after  the  beginning  of  the  vicarious  swelling, 
at  which  time  the  tumor  ruptured  during  a  menstrual  period,  with  the 
occurrence  of  profuse  venous  bleeding.  The  tumor  was  then  excised,  its 
removal  being  followed  at 'the  next  menstrual  period  by  the  occurrence  of 
vicarious  hemorrhage  in  the  breast  gland. 

The  Kidneys. —  Cases  are  recorded  in  which  vicarious  menstruation  is 
said  to  have  assumed  the  form  of  hematuria.  Ford's  patient,  for  example, 
is  stated  to  have  suffered  with  bleeding  of  this  sort  every  month.  She  was 
thirty-two  years  old,  very  hysterical,  and  suffered  also  with  a  floating  right 
kidney.  The  difficulties  of  excluding  actual  kidney  disease  in  cases  of  this 
type  are  obvious.  Cuturi  and  Dschigit  report  similar  cases  of  vicarious 
menstrual  hematuria. 

Old  Cicatrices. —  Kerley  reports  vicarious  hemorrhage  from  a  cicatrix 
over  the  cricoid  cartilage,  to  the  left  of  the  mid-line  of  the  larynx,  in  a  girl 


VICARIOUS  MENSTRUATION  265 

of  twenty-five.  Every  twenty-eight  days,  during  the  menstrual  periods, 
this  cicatrix  would  break  and  discharge  from  four  to  six  ounces  of  blood. 
There  was  very  little  flow  from  the  vagina. 

Abdominal  Fistulae. —  A  case  is  reported  by  Bircher  in  which  there 
was  a  bloody  discharge  at  regular  monthly  intervals  from  a  fistulous  tract 
remaining  after  ventrofixation  of  the  uterus.  The  formation  of  the  fistula 
followed  the  development  of  a  large  subcutaneous  hematoma,  and  Bircher 
makes  an  interesting  observation  in  this  connection.  He  finds  that  the 
overwhelming  majority  of  such  postoperative  hematomata  occur  in  patients 
who  are  operated  upon  within  a  few  days  before  menstruation  begins.  He 
suggests  that  the  susceptibility  to  hematomata  at  this  time  may  be  due  to 
some  change  in  the  blood,  such  as  a  lessening  of  its  coagulability. 

The  Umbilicus. —  A  case  of  vicarious  umbilical  menstruation  is  re- 
ported by  Gardner,  whose  patient  was  a  Polish  girl  of  sixteen.  For  three 
successive  months,  at  the  menstrual  periods,  there  was  observed  a  hemor- 
rhage from  the  umbilicus  lasting  from  twenty-four  to  forty-eight  hours. 
Being  frightened  at  this,  she  wore  a  tight  band  about  the  abdomen.  Fol- 
lowing this  the  umbilical  hemorrhage  is  stated  to  have  ceased,  and  to  have 
been  replaced  by  severe  epistaxis  and  hemoptysis.  It  is  probable  that  such 
cases  of  umbilical  menstrual  hemorrhage  are  due  to  the  presence  of 
miillerian  duct  remnants,  as  described  by  Cullen. 

Other  Seats  of  Vicarious  Menstruation. —  In  addition  to  the  above 
sources  of  vicarious  menstruation,  sporadic  cases  have  been  described  in 
which  the  hemorrhage  came  from  such  sources  as  the  teeth  and  gums 
(Beers),  varicose  and  carcinomatous  ulcers,  the  external  auditory  meatus, 
the  nails,  hemorrhoids,  and  the  stumps  of  amputated  extremities  (Puech). 

Menstrual  History  in  Cases  of  Vicarious  Menstruation. —  In  almost 
all  of  the  reported  cases  of  vicarious  menstruation,  uterine  menstruation  has 
been  either  absent  or  scantier  than  normal.  Occasionally  it  is  described  as 
excessive.  In  a  large  proportion  of  cases  menstruation  is  irregular,  amenor- 
rhea being  frequently  noted.  It  is  especially  at  the  extremes  of  menstrual 
life,  i.e.,  puberty  and  the  menopause,  that  the  vicarious  phenomenon  is  apt 
to  appear.  Especially  frequent  is  it  at  the  climacterium.  A  number  of 
cases  have  been  noted  after  hysterectomy,  the  normal  flow  being  replaced 
by  hemorrhage  from  some  other  organ,  most  frequently  the  nose. 

Vicarious  Menstruation  During  Pregnancy. —  As  a  rule,  vicarious 
menstruation  ceases  when  pregnancy  supervenes.  Norton,  however,  re- 
ports an  unusual  case,  in  which  both  uterine  menstruation  and  a  severe 
vicarious  hemorrhage  from  the  lungs  persisted  throughout  the  entire  dura- 
tion of  pregnancy.  The  patient  had  suffered  with  the  vicarious  hemoptysis 
for  many  years  before  pregnancy  occurred.  The  uterine  hemorrhage  dur- 
ing pregnancy,  as  before,  was  slight  in  amount.  The  case  was  observed 
by  Norton  throughout  pregnancy,  which  terminated  in  a  perfectly  normal 
confinement. 

Cause  of  Vicarious  Menstruation. —  No  satisfactory  explanation  of 


266  MENSTRUATION  AND  ITS  DISORDERS 

this  phenomenon  has  as  yet  been  offered.  Most  of  the  theories  which  have 
been  sugg'ested  assume  that  menstruation  is  not  a  local  process,  but  that  it 
affects  the  woman's  entire  organism.  Hirschberg,  for  example,  compares 
it,  from  this  standpoint,  to  pregnancy,  which  likewise  exerts  a  profound 
systemic  effect  on  the  woman.  Various  hypotheses  have  been  suggested  as 
to  what  this  systemic  effect  of  menstruation  is.  Barnes,  in  reviewing  the 
explanations  which  have  been  offered  for  the  phenomenon,  mentions  the 
following  theories:  (i)  that  it  is  caused  by  plethora;  (2)  that  it  is  the 
result  of  a  weakened  condition  of  the  tissues,   due  perhaps  to  heredity; 

(3)  that  it  is  due  to  an  abnormality  in  the  structure  of  the  blood  vessels; 

(4)  that  it  is  dependent  upon  a  loss  of  the  normal  integument,  as  in  the 
case  of  wounds  or  ulcers.  More  recently  Condit  lays  emphasis  upon  blood 
pressure  changes  occurring  at  the  time  of  menstruation.  It  has  not,  how- 
ever, been  satisfactorily  demonstrated  that  menstruation  is  associated  with 
important  changes  in  blood  pressure,  nor  would  such  a  hypothesis  explain 
the  predilection  for  certain  organs  as  the  seat  of  the  hemorrhage. 

The  very  periodicity  of  vicarious  menstruation  suggests  at  once  that  the 
ovary  is  primarily  responsible  for  its  occurrence,  just  as  in  the  case  of  the 
normal  menstrual  flow.  The  latter  is  apparently  due  to  a  selective  action 
of  the  ovarian  hormone  upon  the  menstrual  apparatus  in  the  pelvis,  espe- 
cially the  blood  vessels  and  the  endometrium.  The  substance  must,  how- 
ever, circulate  throughout  the  entire  blood  stream,  as  do  all  hormones.  It 
is  conceivable  that  in  certain  rare  cases  there  is  present  in  various  tissues  an 
abnormal  sensitiveness  to  the  action  of  the  ovarian  hormone,  analagous  to 
the  normal  receptivity  to  its  influence  of  the  endometrium.  In  the  case  of 
the  nose,  for  example,  the  vestigial  relationship  which  the  latter  is  believed 
to  have  with  the  reproductive  apparatus  would  make  it  easy  to  understand 
why  the  nasal  mucosa  should  occasionally  respond  to  the  ovarian  stimulus, 
with  hyperemia  and  hemorrhage  as  the  result. 

This  explanation  of  vicarious  menstruation  is  not,  of  course,  susceptible 
of  proof  in  the  present  state  of  our  knowledge.  I  mention  it  merely  as  a 
hypothesis,  and  because  it  impresses  me  as  fitting  in  better  than  any  other 
hypothesis  with  our  newer  knowledge  of  the  phenomenon  of  menstruation. 

Diagnosis. —  The  diagnosis  of  vicarious  menstruation  is  never  justi- 
fied by  observation  of  only  one  menstrual  period.  The  sine  qua  non  in  the 
diagnosis  is  the  regular  occurrence  of  the  abnormal  extragenital  hemorrhage 
at  the  menstrual  epochs.  It  is  usually  necessary,  therefore,  to  observe  the 
patient  over  a  period  of  several  months,  unless  her  history  of  the  past 
periodic  hemorrhages  is  unmistakable  and  reliable. 

The  possibilities  for  error  in  diagnosis  are  many  and  obvious.  Beyond 
question  many  cases  which  have  been  reported  as  instances  of  vicarious 
menstruation  are  due  to  other  causes,  such  as  ulcer  of  the  stomach,  pul- 
monary tuberculosis,  etc.  The  opposite  error,  i.  e.,  of  mistaking  vicarious 
menstruation  for  such  definite  pathological  diseases  as  those  mentioned,  is 
far  less  common.     The  diagnosis  of  vicarious  menstruation  should  never  be 


VICARIOUS  MENSTRUATION  267 

made  until  after  thorough  and  repeated  physical  examination,  together  with 
the  many  invaluable  laboratory  aids  which  modern  medical  science  offers 
(X-ray  examination,  stomach  analysis,  urinalysis,  examination  of  the 
stools,  etc.). 

On  the  other  hand,  the  existence  of  a  definite  pathological  lesion  in  the 
lungs,  stomach,  or  elsewhere,  does  not  preclude  the  occurrence  of  vicarious 
menstruation  from  those  organs.  So  long  as  the  hemorrhage  takes  place 
characteristically  at  each  menstrual  period,  the  diagnosis  of  vicarious  men- 
struation, in  the  ordinary  acceptation  of  the  term,  would  seem  to  be 
justified. 

Treatment. —  Since  so  little  is  known  of  the  cause  of  vicarious  men- 
struation, its  treatment  must  of  necessity  be  more  or  less  along  general 
lines.  The  milder  cases,  especially  of  the  nasal  type,  may  need  no  treatment 
except  perhaps  rest  during  the  menstrual  periods.  In  the  more  severe 
cases,  more  vigorous  measures  may  be  necessary  for  the  control  of  the 
bleeding.  These  differ  somewhat  according  to  the  seat  of  the  hemorrhage, 
and  their  consideration  need  scarcely  be  included  in  a  work  of  this  sort. 

XXIII 
LITERATURE 

BiRCHER,     Eine  Seltene  Form  der  Vikariienden   Menstruation.     Zentralb.  f. 

Gyn.,  1910,  34,  952. 
Bloom.     Vicarious  Hemorrhage  from  a  Facial  Naevus.     Arch.  Pediat,  1897, 

14,  693. 
BoGGESs.     Vicarious  Hemorrhage  from  the  Lungs.     Med.  Council,  1899,  55, 

136. 
Chadbourne.     a  Case  of  Vicarious  Menstruation  from  the  Lungs.     Jour.  A. 

M.  A.,  1898,  30,  187. 
CoNDiT.     Compensatory  Vicarious,  Ectopic  Menstruation :  Xenomena.    Amer. 

J.  Obst,  1916,  Ji,  238. 
CouGHLiN.     Vicarious  Menstruation,  with  Report  of  Cases.     Med.  Rec,  1898, 

53,  803. 
Darnall.     Vicarious  Menstruation.     Med.  Rec,  1898,  54,  385. 
Ford.     Two  Cases  of  Vicarious  Menstruation.     Amer.  J.  Obst.,  1889,  22,  154, 
Gardner.     Vicarious  Menstruation  from  Umbilicus.     Med.  Rec,  1898,  54,  173. 
Gillmore.     Absence  of  the  Uterus,  Associated  with  Bilateral  Ovarian  Hernia 

and  Vicarious  Hemorrhage.     Amer.  J.  Obst.,  1906,  53,  520. 
Gleason.     Ocular  Evidences  of  Vicarious  Menstruation.     J.  Mich.  St.  Med. 

Soc,  1916,  15,  336. 
Hauptman.     Vikariiende     Menstruation     in     Form     von     Lippenblutungen. 

Miinch.  Med.  Wchnsch.,  1909,  54,  21 14. 
HiRSCHBERG.     Uber    die    Vikariiende    bzw.    Komplementare    Menstruation. 

Zentralb.  f.  Gyn.,  1914,  38,  929. 
Holmes.     Vicarious  Menstruation,  Resulting  Fatally.     Boston  M.  and  Surg. 

J.,  1889,  120,  108. 


268  MENSTRUATION  AND  ITS  DISORDERS 

Kelsey.     Vicarious  Menstruation.     N.  Y.  Med.  J.,  1891,  54,  719. 

Kerley.     Case  of  Vicarious  Menstruation.     New  York  J.   Gyn.  and  Obst., 

1892,11,74. 
KoBER.     tJber    Vicariirende    Menstruation    durch    die    Lungen.      Berl.    klin. 

Wchnsch.,  1895,  32,  32. 
KuTTNER.     tJber  Magenblutungen  und  besonders  uber  deren  Beziehungen  zur 

Mensftruation.     Berl.  klin.  Wchnsch.,  1895,  32,  142,  168 
Macht.     Vicarious  Epistaxis  in  the  Menopause.     Am.  J.  Obst.,  1910,  61,  645. 
Markarian.     Kasuistischer   Beitrag   zu    den    Krankheitsbilde    **  Vikariiende 

Blutungen."     BerHn,  1910, 
McKenna.     Case  of  Vicarious  Menstruation.     Brit.  M.  J.,  1898,  2,  718. 
Norton.     Vicarious  Menstruation  During  Pregnancy.     Am.  J.   Obst.,   1892, 

25,  218. 
Panyrek.     Vicarious    Menstruation    from    an    Ulcerated    Carcinoma.     Lek. 

Rozhledy,  Prague,  1909,  17,  JZ- 
Parsons.     Vicarious  Menstruation.     Brit.  M.  J.,  1888,  2,  939. 
Ratjen.     Vicariirende  Menstruation.     Centralbl.  f.  Gyn.,  1893,  i?,  642. 
Roth.     Vikariiende  Menstruation  Monats.  f.  Geb.  u.  Gyn.,  1920,  51,  41. 
Smithies  and  Bowen.     Clinical  Significance  of  Gastrorrhagia.    Illinois  M.  J., 

1916,  30,  126. 
Thornton.     Continuous  Vicarious  Menstruation  from  Breasts.     Jour,  A.  M. 

A.,  1909,  52,  211. 
Vickery.     Vicarious  Menstruation.     Boston  M.  and  S.  Jour.,  1888,  119,  604. 
Voigt.     Vikariiende  Menstruation.     Centralbl.  f.  Gyn.,  1893,  17,  642. 
Walker.     Nasal  Menstruation,     Jour.  A.  M.  A.,  1908,  51,  1077. 
Weil.     Les  hemorragies  supplementaires,  etc.    Bull.  Med.,  Paris,  1913,  'Z'j,  37. 
Windmuller.     Vicariiende  Menstruation,     Centralb.  f,  Gyn.,  1893,  17,  643. 
WiTHROw.     Congenital  Amenorrhea  and  Vicarious  Menstruation.     Amer.  J. 

Obst.,  1892,  25,  164. 


CHAPTER  XXIV 

MENSTRUATION  AND  THE  ENDOCRIN  GLANDS 

Introductory. —  The  importance  to  the  surgeon  of  a  thorough 
knowledge  of  anatomy  has  long  been  universally  recognized.  It  is  only 
in  recent  years,  however,  that  we  have  come  to  appreciate  the  value  of  a 
similar  knowledge  of  the  physiology  of  the  various  organs  as  related  to 
their  surgical  diseases.  As  regards  the  surgery  of  the  pelvic  organs,  it  is 
perhaps  true  that  the  gynecologist  has  paid  due  respect  to  such  conspicuous 
physiological  phenomena  as  menstruation,  ovulation,  and  pregnancy,  al- 
though even  these  are  far  from  being  thoroughly  understood.  There  are, 
however,  other  aspects  of  the  physiological  activities  of  the  female  reproduc- 
tive organs  which,  while  bearing  with  perhaps  less  force  upon  the  surgery 
of  these  organs,  still  offer  many  points  of  interest  and  value,  which  make 
them  well  worth  our  careful  study. 

Characteristics  of  Endocrine  Bodies. —  Of  especial  interest  is  a  study 
of  the  physiological  connections  between  the  pelvic  organs  and  the  various 
ductless  glands.  Viewed  in  a  broad  sense,  every  organ  and  tissue  in  the 
body  possesses  an  internal  secretory  function,  for  each  one  gives  off  to  the 
blood  stream  one  or  more  substances  capable  of  influencing  organs  and 
tissues  far  distant  in  the  body.  In  the  case  of  the  so-called  ductless  glands 
(blutgefassdriisen)  the  internal  secretion  is  characterized  by  certain  more 
or  less  striking  and  specific  effects. 

The  designation  of  "  endocrine  organs  "  would  seem  to  be  preferable  to 
that  of  "  ductless  glands,"  for  the  function  of  internal  secretion  is  not 
confined  to  glands  which  possess  no  ducts.  Perhaps  the  best  example  of  a 
gland  possessing  both  external  and  internal  secretions  is  the  testis.  To  the 
same  group  belongs  the  ovary,  if  we  look  upon  the  periodic  discharge  of  ova 
as  a  species  of  external  secretion. 

The  Principal  Endocrine  Structures,  and  their  Importance  to  the 
Body  Economy. —  The  principal  endocrine  organs,  in  addition  to  the 
reproductive  glands,  i.  e.,  the  ovary  or  testis,  are  the  thyroid,  parathyroid, 
pituitary,  suprarenal,  thymus,  pineal  body,  and  spleen.  Our  knowledge  of 
the  physiology  of  most  of  these  structures  is  still  extremely  imperfect,  but 
enough  is  known,  in  the  case  of  some  of  them,  to  indicate  how  widespread 
and  how  important  is  their  influence  on  the  body  functions.  When  we  con- 
sider that  height,  weight,  sexual  development,  and  mentality,  as  well  as 
many  other  body  characteristics,  are  all  largely  dependent  upon  the  various 

269 


270  MENSTRUATION  AND  ITS  DISORDERS 

internal  secretions,  we  may  well  say  that  an  individual  is  just  about  what 
his  endocrine  system  makes  him. 

For  the  consideration  of  the  entire  subject  of  internal  secretions  I  would 
refer  the  reader  to  the  well  known  treatises  of  Biedl  and  Falta.  The  recent 
work  of  Bell  is  an  excellent  presentation  of  the  relation  of  the  internal 
secretions  to  the  reproductive  organs.  I  would  also  commend  to  the  reader 
a  perusal  of  the  number  of  Surgery,  Gynecology  and  Obstetrics  for  Septem- 
ber of  1 91 7,  inasmuch  as  it  is  devoted  to  the  publication  of  the  valuable 
papers  read  in  the  symposium  on  "  The  Relation  of  the  Glands  of  Internal 
Secretion  to  Gynecology  and  Obstetrics,"  which  was  held  by  the  American 
Gynecological  Society  at  its  19 17  meeting. 

In  the  present  chapter  it  would  seem  proper  to  limit  ourselves  to  a  brief 
consideration  of  the  relation  of  the  more  important  endocrine  glands  to  the 
reproductive  organs,  with  special  reference  to  their  influence  on  the  function 
of  menstruation. 

THE  OVARY 

The  Ovary  as  an  Endocrine  Gland. —  The  relation  of  the  ovary  to 
menstruation  has  already  been  fully  considered  in  the  discussion  of  the 
causation  of  this  phenomenon  (Chapter  VII).  Here  we  need  add  only  a 
word  as  to  the  general  importance  of  the  ovary  in  the  body  economy,  and 
some  of  its  more  important  connections  with  other  endocrine  glands.  Al- 
though it  is  certain  that  the  ovary  and  testis  are  of  fundamental  importance 
in  the  determination  of  the  secondary  sexual  characteristics  which  distin- 
guish the  sexes,  it  must  be  emphasized  that  other  endocrine  glands,  especially 
the  thyroid  and  pituitary,  play  an  important  contributory  role  in  this  respect. 
Bell  concisely  sums  up  the  evolution  of  our  ideas  concerning  this  subject  as 
follows :  "  Van  Helmont  said  '  Propter  solum  uterum  mulier  est  quod  est.' 
Later  Chereau  changed  this  to  '  Propter  ovarium  solum  mulier  est  quod 
est'  Virchow  in  modern  times  reiterated  this  statement,  and,  according  to 
Biedl,  added  'All  the  peculiarities  of  her  body  and  mind,  .  .  .  every- 
thing, in  fact,  which  in  the  true  woman  we  admire  and  revere  as  womanly, 
is  dependent  on  the  ovary.'  But  in  the  light  of  our  present  knowledge  I 
venture  to  think  that  the  following  aphorism  most  accurately  represents  the 
cause  and  efifect,  '  Propter  secretiones  internas  totas  mulier  est  quod  est.'  " 

The  Part  Played  by  the  Ovary  at  Puberty  and  at  the  Menopause. — 
The  characteristic  changes  brought  about  in  the  uterus  and  other  pelvic 
organs  at  the  time  of  puberty  have  already  been  described  (Chapter  IX). 
They  are  unquestionably  due  primarily  to  the  inauguration  of  ovarian  func- 
tion. In  the  same  way,  the  retrogressive  changes  of  the  menopause 
(Chapter  XIII)  are  due  to  cessation  of  ovarian  function. 

Castration  in  Early  Life. —  In  the  humain  being  castration  is  a  rare 
operation  before  the  age  of  puberty,  and  hence  accurate  observations  of  the 
results  are  very  scanty.  Experimental  studies  in  the  lower  animals,  how- 
ever, indicate  that  removal  of  the  ovaries  in  early  life  causes  an  inhibition  of 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  271 

the  normal  development  of  the  sexual  apparatus.  Estrus,  of  course,  fails 
to  appear. 

The  Surgical  Menopause  and  its  Manifestations. —  The  results  of 
castration  performed  during  the  child  bearing  age  in  women  are  much 
better  known,  on  account  of  the  relative  frequency  of  double  oophorectomy 
during  that  period.  In  former  years  the  operation  was  far  more  commonly 
done  than  now.  Complete  removal  of  ovarian  tissue  is  followed  by  marked 
retrogressive  changes  throughout  the  entire  generative  tract,  comparable  to 
those  which  are  normally  observed  at  the  time  of  the  menopause.  The 
external  genitalia  undergo  atrophy,  the  skin  being  shriveled,  and  the  mucosa 
becoming  thin  and  anemic.  Owing  to  the  replacement  of  the  epithelium 
by  cicatrix-like  connective  tissue,  there  is  often  more  or  less  contraction  of 
the  vagina.  The  uterus  becomes  smaller,  so  that  the  cervix  is  often  scarcely 
raised  above  the  vaginal  mucosa.  As  at  the  menopause,  the  mammary 
glands  undergo  atrophic  changes.  In  spite  of  this  the  breasts  sometimes 
become  much  larger  than  before,  the  atrophy  of  the  gland  elements  being 
more  than  compensated  for  by  the  deposit  of  adipose  tissue.  This  tendency 
to  deposit  fat  is  in  a  considerable  proportion  of  cases  a  general  one,  the 
woman's  weight  often  being  increased  by  many  pounds.  As  an  explanation 
for  this,  reference  may  be  made  to  the  results  of  Lowy  and  Richter,  who 
found  that  castration  is  followed  by  a  diminution  of  from  14  to  20  per  cent 
in  the  oxidation  processes  of  the  body,  as  determined  by  the  respiratory 
gaseous  interchange. 

As  regards  the  effect  of  oophorectomy  upon  the  structure  of  other  endocrine 
oflands,  Bell  states  that  in  rodents  there  is  a  "  considerable  increase  of  func- 
tional  activity  oi  the  thyroid,"  so  far  as  colloid  production  is  concerned; 
and  that  there  is  a  "  certain  increase  in  the  secretory  activity  of  the  anterior 
lobe  of  the  pituitary  body."  The  thymus,  he  believes,  undergoes  hyper- 
trophy after  castration,  while  the  effects  of  the  operation  on  the  suprarenal 
and  pineal  bodies  are  more  or  less  uncertain. 

Perhaps  even  more  important  than  the  anatomical  changes  consequent 
upon  castration  are  the  subjective  symptoms  so  often  observed.  It  is 
scarcely  necessary  to  enumerate  these  here,  for  they  are  identical  with  those 
which  are  characteristic  of  the  normal  menopause,  already  described  else- 
where (Chapter  XIII).  The  impression  has  been  prevalent  among  many 
gynecologists,  that  these  symptoms  are  apt  to  be  more  severe  the  earlier  in 
life  the  ovaries  are  removed.  This,  as  Culbertson  shows,  is  not  borne  out 
by  the  facts.  I  have  personally  been  impressed  with  the  remarkably  slight 
subjective  effect  produced  in  many  instances  by  removal  of  both  ovaries, 
when  this  is  necessitated  in  young  women. 

The  conclusion  to  be  drawn  from  our  present  knowledge  of  the  subject 
would  seem  to  be  that  the  degree  of  menopausal  reaction,  whether  natural  or 
surgical,  is  dependent  upon  the  individual  factor,  and  that  in  all  cases  where 
conservation  of  healthy  ovarian  tissue  is  possible,  it  should  be  practiced-. 
This  is  especially  important  in  young  individuals. 


272  MENSTRUATION  AND  ITS  DISORDERS 

On  the  other  hand,  important  as  the  ovary  may  be  to  a  woman's  well- 
being,  it  cannot  be  looked  upon  as  a  vital  organ  or  even  as  indispensable  to 
good  health.  Without  both  ovaries,  the  woman  may  still  enjoy  the  best  of 
health,  and  may  even  be  spared  any  troublesome  degree  of  temporary  meno- 
pausal disturbance.  For  this  reason  it  would  seem  unwise  to  strain  conser- 
vatism to  the  point  of  saving  affected  ovaries  in  cases,  for  example,  of 
extensive  pelvic  inflammatory  disease  at  or  near  the  age  of  the  menopause, 
especially  in  the  case  of  women  who  have  already  borne  many  children. 

In  such  cases  the  question  of  subsequent  pregnancy  is  usually  of  subor- 
dinate importance,  the  woman's  sole  desire  being  to  get  well  and  stay  well. 
Even  the  most  conservative  of  surgeons  will  admit  that  quite  frequently 
secondary  operations  follow  efforts  at  conservatism,  and  in  the  hypothetical 
case  just  mentioned  it  does  not  seem  justifiable  to  expose  the  woman  to 
this  risk,  in  return  for  the  slight  advantage  represented  by  the  preservation 
for  a  short  period  of  the  internal  secretion  of  the  ovary.  Each  case  must 
be  judged  on  its  own  merits,  social  considerations  often  weighing  just  as 
heavily  as  cold  scientific  facts. 

Cause  of  Symptoms  of  Artificial  Menopause. —  It  v^as  formerly  be- 
lieved that  the  unpleasant  results  produced  by  removal  of  the  ovaries  are 
dependent  upon  a  disturbance  of  the  nervous  system.  The  experimental 
work  of  Knauer,  and  also  that  of  Marshall  and  Jolly,  has  shown  that  the 
effects  of  ovarian  removal  are  due  to  the  withdrawal  of  the  hormone  or 
hormones  of  that  organ  (see  Chapter  VII).  A  modification  of  this  view  is 
suggested  by  Graves,  who  believes  that  the  symptoms  of  the  artificial  meno- 
pause are  the  result  of  a  '*  disturbance  of  the  utero-ovarian  functional 
harmony,"  rather  than  to  mere  withdrawal  of  the  ovarian  hormone. 

Transplantation  of  the  Ovaries. —  A  demonstration  of  the  internal 
secretory  function  of  the  ovary  is  furnished  by  a  certain  proportion  of  the 
now  large  number  of  cases  in  which  ovarian  tissue  has  been  transplanted  in 
human  beings.  In  the  majority  of  reported  cases  the  operation  has  con- 
sisted in  the  transplantation  of  ovarian  tissue  from  the  normal  location  to 
another  part  of  the  same  individual  {autotransplantation) .  Quite  fre- 
quently, however,  the  procedure  has  been  one  of  homotransplantation,  i.  e., 
from  one  human  being  to  another.  In  a  small  proportion,  finally,  hetero- 
transplantation has  been  attempted,  ovarian  tissue  being  transplanted  from 
an  animal  of  another  species.  Several  reviews  of  the  entire  subject  have 
lately  been  published,  notably  those  of  Martin,  Tuffier,  and  Chalfant.  To 
these  the  reader  is  referred  for  detailed  information. 

General  Results. —  The  results  so  far  obtained  with  autotransplantation 
have  been  much  more  successful  than  in  the  case  of  the  other  two  types  of 
operation,  and  it  appears  to  have  a  field  in  a  certain  small  proportion  of 
cases,  i.  e.,  those  in  which,  because  of  some  such  reason  as  disturbance  of  its 
blood  supply,  the  ovary  cannot  be  allowed  to  remain  in  its  normal  position. 
Heterotransplantation  is  only  rarely  successful,  although  in  at  least  two 
cases  it  was  followed  by  pregnancy  (Groom,  Morris).     Even  when  the  graft 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  273- 

"takes,"  the  operation  is  often  unsuccessful  from  a  physiological  point  of 
view,  for  as  a  rule  the  transplanted  ovarian  tissue  soon  undergoes  atrophy. 

Operative  Technic  of  Autotransplantation  of  Ovarian  Tissue. — 
The  reasons  for  failure  in  transplantation  of  the  ovary,  certainly  in  the  case 
of  autografts,  appear  to  lie  almost  altogether  in  the  technic  employed  in  the 
operation.  A  number  of  different  methods  have  been  proposed.  Tuffier, 
who  had  performed  the  operation  of  ovarian  transplantation  204  times,  up 
to  July  of  1914,  describes  his  technic  as  follows : 

"  I  take  the  ovary,  or  a  portion  of  it,  in  a  sterilized  compress ;  the  peri- 
toneum of  the  abdominal  wall  is  supported  by  the  finger  deeply  inserted  into 
the  adipose  tissue,  and  the  ovary  put  into  this  opening  and  left  there. 
When  the  glands  are  surrounded  by  adhesions  they  are  often  torn  in  freeing 
them,  their  surface  becomes  irregular,  and  they  appear  wasted.  Often,  also, 
they  are  sclerosed  or  contain  cysts,  but  even  in  such  instances  the  glands 
may  be  made  use  of  and  the  results  are  good.  If  the  glands  are  not  quite 
aseptic,  they  may  be  dipped  into  tincture  of  iodin  or  passed  through  the 
flame  of  a  lamp.  The  result  in  these  cases,  however,  is  not  so  good.  In 
cases  of  cystic  change  the  ovaries  must  be  opened  before  grafting.  A  small 
section  of  the  pedicle  of  the  gland  is  sometimes  needed  to  enlarge  the  sur- 
face for  future  adhesions.  In  some  recent  cases  the  glands  were  divided 
into  equal  parts  and  implanted  separately.  This  is  done  in  order  to  obtain 
the  smaller  grafts  and  larger  surfaces  for  adhesions." 

The  results,  in  so  far  as  the  preservation  of  the  menstrual  function  is 
concerned,  have  been  satisfactory.  This  is  especially  true  of  the  cases  in 
which  autografts  were  used.  Of  sixty-five  of  these,  Tuffier  states  that  he 
had  interviewed  thirty-seven  from  one  to  six  years  after  operation,  and 
found  that  thirty-two  menstruated  regularly. 

The  technic  employed  by  Simpson,  as  detailed  by  Chalfant,  differs  some- 
what from  that  just  described.  "A  section  measuring  about  2x23^  cm.  is 
cut  from  the  cortex  of  the  ovary  to  be  grafted,  and  this  is  inserted,  through 
a  small  skin  incision,  in  a  pocket  of  the  subcutaneous  tissue,  about  two 
inches  to  the  inner  side  of  the  anterior  superior  spine  of  the  ilium." 

Present  Status  of  Ovarian  Transplantation. —  The  present  status 
of  the  operation  of  ovarian  transplantation  is  so  conservatively  and  wisely 
expressed  by  Martin  in  the  conclusion  of  his  most  recent  paper  on  the 
subject  that  I  can  do  no  better  than  to  quote  him:  "  Careful  sifting  of  the. 
accumulated  literature  of  ovarian  tissue  transplantation  leaves  a  feeling  of 
disappointment  as  to  the  surgical  value  in  the  mind  of  an  impartial  observer. 
Autotransplantation  of  ovarian  tissue,  as  the  operation  is  at  present  prac- 
ticed, retards  and  modifies  the  symptoms  of  the  artificial  menopause  that  is 
precipitated  by  castration  in  a  definite  number  of  cases,  depending  undoubt- 
edly upon  the  ability  of  the  graft  to  retain  its  vitality  in  the  new  environment. 

"  The  percentage  of  successful  results  in  the  autotransplantation  seems  to 
be  as  large  where  the  simplest  technic  is  employed,  using  small  pieces  of 
ovaries  tucked  into  pockets  of  well  vascularized  tissue,  as  when  a  more  com- 


"274  MENSTRUATION  AND  ITS  DISORDERS 

plicated  technic  is  employed  with  an  attempt  to  definitely  couple  up  the 
blood  vessels. 

"  The  fact  that  homotransplants  and  heterotransplants  are  failures,  made 
with  the  same  technic  that  is  employed  for  successful  autotransplants,  demon- 
strates that  there  is  a  definite  antagonism  between  the  tissues  of  different 
mdividuals  of  the  same  species,  and  a  prohibitive  antagonism  between  the 
tissues  of  different  species. 

"  Occasional  reports  of  successful  homotransplants  and  heterotransplants 
encourage  one  to  hope  that  in  some  way  this  antagonism  of  tissue  will  be 
overcome,  and  more  successful  work  may  result  because  of  the  greater 
precision  this  would  make  possible  in  selecting  more  normal  tissue." 

Menstruation  After  Removal  of  the  Ovaries. —  There  are  few  gyne- 
cologists of  experience  who  have  not  encountered  cases  in  which  menstrua- 
tion has  persisted,  even  after  apparently  complete  removal  of  the  ovaries.  A 
distinction  must  be  drawn  between  those  in  which  there  has  been  a  genuine 
return  of  the  function  and  those  in  which  there  has  been  merely  a  bloody 
discharge  soon  after  the  operation,  without  a  tendency  to  regular  recurrence. 
Instances  of  the  latter  type  are  relatively  common. 

"  PsEUDO  Menstruation."  —  The  designation  of  pseudomenstruation, 
applied  to  these  cases  by  some  authors,  is  scarcely  an  appropriate  one,  for 
Neu  looks  upon  bleeding  in  these  cases  as  actually  menstrual  in  character. 
From  the  study  of  54  cases  in  which  both  ovaries  had  been  removed,  he 
concludes  that  when  the  operation  is  performed  after  the  fourteenth  day  of 
the  menstrual  cycle,  a  menstrual  discharge  is  noted  after  the  operation. 
When  the  latter  is  performed  during  the  first  fourteen  days  of  the  cycle,  on 
the  other  hand,  no  such  discharge  occurs.  It  would  seem  from  such  obser- 
vations as  these  that  the  occurrence  of  a  postoperative  menstrual  discharge 
is  explainable  on  the  ground  that,  before  the  ovaries  have  been  removed, 
a  sufficient  amount  of  their  internal  secretion  has  found  its  way  into  the 
blood  stream  to  bring  on  the  next  menstrual  period,  even  though  the  ovaries 
have  meanwhile  been  removed.  This  explanation,  however,  is  not  suscep- 
tible to  proof  in  the  present  state  of  our  knowledge. 

Menstruation  After  Apparently  Complete  Removal  of  Ovaries. — 
Even  more  interesting  are  the  cases  in  which  menstruation  continues  in  a 
normal  manner  for  a  long  period,  perhaps  many  years,  after  supposedly 
complete  removal  of  the  ovaries.  Cases  of  this  type  have  been  recorded  by 
Findley,  Gellhorn,  and  others.  According  to  Pfister,  as  many  as  about  12 
per  cent  of  oophorectomized  women  still  continue  to  menstruate  for  a  longer 
or  shorter  time  after  the  operation.  My  own  experience  makes  me  feel  that 
this  figure  is  much  too  high.  In  addition  to  the  patients  exhibiting  normal 
menstruation  after  such  operative  procedures,  there  are  many  who  suffer 
from  vicarious  hemorrhages,  chiefly  from  the  nose  and  bowel.  Finally,  in 
about  30  per  cent  of  castrated  women,  more  or  less  well  defined  menstrual 
molimina  are  noted. 

Theories  of  Persistence  of  Menstruation  After  Oophorectomy. — 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  275 

A  number  of  theories  have  been  advanced  as  to  the  reason  for  the  persistence 
of  the  menstrual  function  after  removal  of  the  ovaries.  Such  clinical  find- 
ings as  those  of  Pfister,  quoted  above,  furnished  one  argument  to  Halban  in 
support  of  his  contention  that  the  ovaries  themselves  are  not  essential  to 
menstruation,  but  that  they  exert  a  protective  or  activating  influence  upon 
some  other  cause,  as  yet  unknown.  This  view  he  attempts  to  prove  by  his 
studies  on  frogs.  The  practical  importance  of  Halban's  distinction  is  not 
obvious.  Whether  the  ovarian  hormone  is  itself  the  sole  cause  of  the 
menstrual  phenomenon  or  whether  it  is  an  activator  of  some  other  cause 
seems  of  less  importance  than  the  observation  that,  in  either  event,  the 
removal  of  the  ovary  practically  always  stops  menstruation.  It  is  now  con- 
ceded by  all  that  the  menstrual  function  is  under  the  influence  of  the  entire 
endocrine  system,  but  it  can  scarcely  be  denied  that  the  ovary  is  the  link  in 
the  ductless  gland  chain  which  is  most  intimately  bound  up  with  menstrua- 
tion. 

The  explanation  which  is  most  generally  accepted  for  this  phenomenon, 
and  the  one  which  appeals  most  strongly  to  me,  is  that  in  all  cases  in  which 
menstruation  persists  after  oophorectomy,  a  bit  of  ovarian  tissue  has  been 
inadvertently  left  behind  or  else  accessory  ovarian  tissue  must  be  present 
somewhere  in  the  body.  There  can  be  little  question  that  in  most  cases  in 
which  menstruation  continues  after  castration,  the  former  condition  exists, 
i.  e.,  ovarian  tissue  has  been  left  behind.  It  is  difficult  in  many  instances  for 
even  the  expert  operator  to  be  sure  that  all  ovarian  tissue  has  been  removed. 
Cases  are  recorded  by  Doran,  Gordon  and  others,  in  which  pregnancy  had 
subsequently  occurred  in  cases  up  to  that  time  considered  to  exemplify  a 
persistence  of  menstruation  after  castration.  No  better  proof  could  be 
adduced  to  show  that  ovarian  tissue  must  still  have  been  present  in  these 
cases. 

The  question  of  supernumerary  ovaries  and  of  accessory  ovarian  tissue 
must  also  be  considered  in  connection  with  this  question.  Certainly  in  the 
human  being,  the  finding  of  accessory  or  aberrant  ovarian  tissue  is  rare. 
The  studies  of  Meriel  and  others,  however,  indicate  the  possibility  of  this 
occurrence.  According  to  Meriel  such  tissue  may  be  found  in  various  loca- 
tions in  the  pelvis,  such  as  the  broad  ligament,  the  ovarian  ligament,  etc. 
Cases  of  accessory  ovarian  tissue  have  been  reported  by  various  authors 
(Smith  and  Wood). 

The  possibility  of  this  occurrence  cannot  be  eliminated  in  any  case  of 
persistent  menstruation  after  oophorectomy,  especially  since  the  accessory 
ovarian  bodies,  according  to  Meriel,  are  ofttimes  very  tiny. 

There  seems  to  be  no  proof  for  the  various  other  explanations  which  have 
been  advanced  for  the  phenomenon  under  discussion  —  the  so-called  "  men- 
strual habit ; "  the  occurrence  of  the  "  menstrual  wave "  in  the  body 
processes,  as  advanced  by  Jacobi  and  others ;  the  possible  role  of  degenera- 
tive changes  in  the  uterine  blood  vessels  after  operation ;  the  importance 
of  adhesions  to  the  uterus,  etc. 


276  MENSTRUATION  AND  ITS  DISORDERS 

THE  THYROID  GLAND 
Evidences  of  Relation  Between  Thyroid  Gland  and  Gonads. —  In 

view  of  the  fact  that  the  thyroid,  in  certain  of  the  lower  types  of  animal 
life,  empties  its  secretion  directly  into  the  uterine  cavity,  it  is  perhaps  not 
surprising  that  in  the  human  being-  and  other  higher  animals,  an  important 
relation  between  the  thyroid  body  and  the  generative  system  still  persists, 
even  though  they  be  far  removed  anatomically.  That  the  sexual  apparatus 
exerts  an  important  influence  on  the  thyroid  is  suggested  by  a  number  of 
facts.  The  increased  size  of  the  thyroid  often  observed  at  puberty;  the 
swelling  of  the  gland  during  the  menstrual  periods,  and  often  during  preg- 
nancy and  lactation ;  the  thyroid  disturbance  which  may  be  observed  at  the 
time  of  the  menopause;  the  thyroid  hypertrophy  seen  in  animals  after 
experimental  castration ;  the  influence  of  sexual  activity  upon  the  thyroid, 
with  the  occasional  occurrence  of  Graves'  disease  as  a  result  of  sexual 
excesses,  and  the  onset,  in  rare  cases,  of  even  acute  hyperthyroidism  after 
oophorectomy  —  all  these  are  indicative  of  a  close  connection  between  the 
thyroid  function  and  that  of  the  gonads. 

Thyroid  Disease  as  a  Result  of  Pelvic  Lesions. —  Cases  are  recorded 
in  which  thyroid  disease  appears  clearly  to  have  been  the  result  of  coexist- 
ing pelvic  lesions.  Perhaps  the  most  remarkable  instance  of  this  kind  is 
the  case  described  by  Goodall  and  Conn.  The  patient,  a  woman  of 
sixty-nine,  complained  of  "  pelvic  trouble  "  of  two  years'  duration.  During 
the  same  period  she  had  suffered  also  with  loss  of  weight,  tachycardia, 
dyspnea,  and  other  symptoms  of  hyperthyroidism.  The  thyroid  was  as 
large  as  an  ordinary  cocoanut,  while  the  heart  was  dilated,  with  all  the 
signs  of  chronic  myocarditis. 

Operation  was  performed,  after  a  period  of  preliminary  treatment,  on 
account  of  an  ill  defined  pelvic  mass.  The  condition  was  found  to  be  one 
of  advanced  pelvic  tuberculosis,  necessitating  removal  of  the  uterus  and 
appendages.  The  interesting  point  in  the  case  was  the  fact  that  af<-er  the 
twelfth  day  the  thyroid  enlargement  gradually  diminished,  while  the  symp- 
toms disappeared.  About  the  thirtieth  day  the  gland  was  normal,  and 
later  became  even  smaller,  so  that  the  authors  felt  that  she  might  later  suffer 
from  athyria.  Six  months  after  the  operation,  however,  she  was 
"  remarkably  well." 

Menstrual  Disorders  Accompanying  Thyroid  Disease. —  Further  evi- 
dence of  this  interrelation  is  furnished  by  the  menstrual  disorders  which 
are  so  frequently  observed  in  connection  with  hyper-  and  hypothyroidism. 
In  both  myxedema  and  exophthalmic  goitre  menstruation  is  often  dis- 
ordered, but  there  is  no  unanimity  of  opinion  as  to  the  type  of  disturbance 
occurring  in  the  two  conditions.  In  myxedema,  menstruation  is  most  often 
excessive,  although  some  authors,  as  for  example  Goodall  and  Conn,  lay 
stress  upon  amenorrhea  as  a  symptom  of  myxedema.  As  a  matter  of  fact, 
the  effect  of  hypothyroidism  upon  menstruation  appears  to  be  variable, 
although  the  evidence  points  to  menorrhagia  as  more  frequent  than  amenor- 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS 


277 


rhea.  What  the  factors  are  which  determine  this  variabihty  of  influence  it 
would  seem  unprofitable  to  discuss  in  the  present  imperfect  state  of  our 
knowledge. 

Conversely,  as  regards  hyperthyroidism,  it  seems  to  be  fairly  well  estab- 
lished that  amenorrhea  is  more  commonly  associated  than  is  menorrhagia, 
although  here  again,  numerous  exceptions  are  noted.  This  subject  is 
further  discussed  in  Chapter  XXV. 

THE  PITUITARY  BODY 

General. —  Although   there    is    abundant    evidence    of   an    intimate 

physiological  relation  between  the  pituitary  body  and  the  generative  glands, 

there  is  still  much -to  learn  of  the  role 
played  by  the  various  portions  of  the 
hypophysis  in  this  connection.  It  is 
definitely  established,  of  course,  that 
the  active  principle  derived  from  the 
posterior  lobe  (pars  nervosa)  exerts  a 
powerful  eflFect  upon  the  involuntary 
muscle  fibres,  including  the  uterine 
musculature.  It  has  thus  come  into  a 
well  deserved  vogue  in  obstetric  prac- 
tice. Its  other  physiological  effects  need 
not  be  discussed  in  this  place. 

Adiposogenital  Dystrophy. —  Since 
1 90 1,  when  Frohlich  called  attention  to 
the  interesting  syndrome  which  is  now 
well  known  under  the  designation  of 
adiposogenital  dystrophy,  the  influence 
of  the  pituitary  in  the  development  of 
the  sexual  glands  has  been  recognized. 
The  cardinal  symptoms  of  adiposogeni- 
tal dystrophy  are  obesity  and  sexual 
hypoplasia.  In  women  the  sexual  hypo- 
plasia manifests  itself  clinically  through 
amenorrhea.  Fig.  40  illustrates  well  the 
type  of  figure  characterizing  Frohlich's 
syndrome. 

Cases  of  hypopituitary  amenorrhea 
are  encountered  with  great  frequency. 
I  have  records  of  a  considerable  number 
which  I  have  observed  myself.  A  typical 
history  is  as  follows :  Mrs.  C,  aged 
twenty-seven,  consulted  me  for  the  pur- 


Pi(j.  40. —  Dystrophia  Adiposogenitalis 
(Falta). 


pose  of  finding  out  whether  or  not  she 


278;  MENSTRUATION  AND  ITS  DISORDERS 

was  pregnant.  She  had  not  menstruated  for  seven  months,  and  had,  as  she 
expressed  it,  grown  much  larger.  Forty  pounds  had  been  gained  within  a 
year.  There  were  no  subjective  symptoms  of  pregnancy,  and  examination 
revealed  tliat  she  was  not  pregnant.  The  case  was  evidently  to  be  regarded 
as  belonging  to  the  adiposogenital  group. 

There  has  been  some  fluctuation  of  opinion  as  to  which  portion  of  the 
pituitary  is  concerned  in  these  changes.  The  weight  of  evidence  at  the 
present  time  is,  however,  definitely  in  favor  of  the  view  that  the  sexual 
hypoplasia  is  a  result  of  deficiency  of  the  anterior  lobe.  It  is  probably  true, 
however,  that  the  posterior  lobe  is  responsible  for  the  increased  carbohydrate 
tolerance  often  noted  in  this  condition. 

Influence  of  Pituitary  on  Body  Growth. —  It  is  of  interest  to  note 
that  the  same  portion  of  the  pituitary,  i.  e.,  the  anterior  lobe,  is  looked  upon 
as  influential  in  the  stimulation  of  body  growth.  According  to  Robertson, 
the  latter  is  a  complex  process,  and  he  believes  that  "  an  agency  which 
causes  retardation  of  growth  at  a  certain  stage  in  the  development  of  a 
mammal  may  actually  lead  to  acceleration  of  growth  at  some  other  stage  in 
the  development  of  the  same  animal."  He  has  succeeded  in  isolating  from 
the  anterior  lobe  a  potent  growth  controlling  substance  which  he  calls 
tethelin.  Whether  or  not  this  substance  will  be  of  service  in  combating 
the  sexual  changes  associated  with  deficiency  of  the  anterior  lobe  remains 
to  be  worked  out.  Gotsch,  on  the  other  hand,  is  inclined  to  believe  that 
the  varying  results  reported  by  different  authors  as  to  the  effect  of  feeding 
pituitary  to  animals  are  due  to  differences  in  dosage  and  activity  of  the 
preparation  used  rather  than  to  the  influence  of  the  age  of  the  animal.  The 
recent  experimental  work  of  Frank,  however,  leads  him  to  doubt  whether 
the  use  of  pituitary  extracts  has  any  stimulating  effect  upon  the  sex  organs 
of  the  female. 

Pituitary  Hypertrophy  in  Pregnancy. —  As  in  the  case  of  the  thyroid, 
a  physiological  hypertrophy  of  the  pituitary  may  be  observed  in  connection 
with  pregnancy.  This  has  been  put  beyond  the  realm  of  speculation  by  the 
work  of  Erdheim  and  Stumme,  who  were  able  to  demonstrate  this  enlarge- 
ment in  pregnancy  by  means  of  X-ray  studies,  and  who  also  gave  an  accu- 
rate description  of  the  histological  changes  involved.  The  mild  degree  of 
hyperpituitarism  associated  with  this  form  of  physiological  hypertrophy  no 
doubt  explains  the  acromegaly-like  changes  sometimes  observed  in  preg- 
nancy—  the  heavy,  "thick"  features,  the  enlargement  of  the  fingers,  etc. 
In  rare  cases  the  enlargement  of  the  gland  may  be  sufficient  to  cause 
symptoms  suggestive  of  pituitary  tumor,  such  as  hemianopsia. 

Pituitary  Hypertrophy  After  Castration. —  It  is  of  significance  to 
note  that  hypertrophy  of  the  pituitary  follows  the  operation  of  castration. 
In  the  case  of  the  lower  animals  this  has  been  shown  experimentally  by 
Fischera,  while  Tandler  and  Gross  have  demonstrated  a  similar  change  in 
human  beings,  both  men  and  women. 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  279- 

THE  SUPRARENAL  BODIES 

Difference  in  Function  Between  Cortex  and  Medulla. —  There  is  a 
very  striking  difference  of  function  between  the  two  portions  of  the  supra- 
renal body,  i.  e.,  the  medulla  and  the  cortex.  The  former,  which  develop- 
mentally  is  a  part  of  the  sympathetic  nerve  system,  is  also  closely  allied 
with  the  latter  from  a  functional  point  of  view.  It  constitutes  a  part  of  the 
so-called  chromaffin  system.  The  cortex,  on  the  other  hand,  is  developed 
from  the  mesodermic  epithelium  covering  the  fore  part  of  the  wolffian 
body,  having  the  same  "  anlage  "  as  the  ovary  or  testis.  It  is  not  surpris- 
ing, therefore,  that  the  suprarenal  cortex  appears  to  exert  a  very  important 
influence  on  the  reproductive  organs. 

Indications  of  Relation  Between  Function  of  Suprarenals  and 
Gonads. —  This  interesting  relationship  was  recognized  as  far  back  as 
1806,  when  Meckel  reported  a  case  of  absence  of  the  suprarenals  and  the 
sexual  glands  in  an  acardiac  monster.  He,  at  that  time,  expressed  the 
opinion  that  animals  possessing  strong  sexual  powers  have  well  developed 
suprarenals.  It  is  stated  that  in  rabbits  there  is  a  marked  hypertrophy  of 
the  adrenal  cortex  during  pregnancy,  and  that  in  birds  and  amphibians  the 
adrenals  increase  in  size  during  the  breeding  seasons.  It  would  seem 
likely  that  similar  changes  occur  in  human  beings,  although  no  proof  of  this 
can  be  offered,  except  perhaps  the  observation  that  during  pregnancy  there 
is  in  some  women  a  tendency  to  hirsutism,  the  "  hypertrichosis  graviditatis  " 
of  Hegar.  A  number  of  investigators  (Schenk,  Thumin,  Soli)  have  found 
that  castration  in  dogs  and  rabbits  is  followed  by  enlargement  of  the  cortex. 

Effects  of  Suprarenal  Tumors  on  Reproductive  System. —  Our 
knowledge  of  the  relations  between  the  adrenals  and  the  sexual  system  in 
human  beings  is  based  almost  altogether  upon  the  clinical  phenomena  asso- 
ciated with  certain  reported  cases  of  suprarenal  tumors.  Bulloch  and 
Sequeira,  in  1905,  reported  a  personal  case  of  this  type,  and  collected  eleven 
others  from  the  literature.  Their  own  case,  which  may  be  considered  fairly 
typical  of  the  group,  was  that  of  a  girl  of  eleven  who  up  to  the  age  of  ten 
had  been  normal.  At  this  age  she  gave  evidence  of  precocious  develop- 
ment. She  became  very  stout,  her  face  presenting  the  appearance  of  a 
woman  of  forty,  whereas  she  had  previously  been  pale  and  thin.  Men- 
struation appeared,  while  her  breasts  became  as  large  as  those  of  a  mature 
woman,  and  the  pubes  and  axillae  were  covered  with  hair.  At  the  same 
time  a  tumor  developed  in  the  abdomen. 

After  death  the  growth  was  found  to  have  arisen  in  the  left  suprarenal 
gland,  and  to  be  composed  of  adrenal  tissue.  All  the  cases  collected  by 
Bulloch  and  Sequeira  occurred  in  children,  most  of  them  below  the  age  of 
seven.  The  same  observation  was  made  by  Glynn,  who  described  five 
additional  cases  in  an  exhaustive  paper  published  in  191 1.  From  a  patho- 
logical standpoint,  the  tumors  in  the  suprarenal  are  carcinomata,  sarcomata, 
or  hypemephromata. 

These  cases  of  precocious  development  associated  with  suprarenal  tumors 


280  MENSTRUATION  AND  ITS  DISORDERS 

are  divided  by  Guthrie  into  two  principal  types,  ( i )  the  obese  type,  met 
with  in  both  sexes ;  but,  apart  from  the  presence  of  pubic  hair,  the  develop- 
ment of  the  sexual  organs  is  not  marked,  though  one  of  the  reported  female 
cases  menstruated.  (2)  The  muscular  or  "  infant  Hercules"  type,  occur- 
ring only  in  males,  who  may  show  true  sexual  precocity. 

Changes  in  Sexual  Apparatus  Associated  With  Suprarenal  Hyper- 
trophy, Without  Tumor. —  It  is  of  interest  to  note  that  sexual  changes 
have  been  observed  with  hypertrophy  of  the  suprarenals,  in  the  absence  of 
any  actual  neoplasm.  Thirteen  cases  of  pseudohermaphroditism,  associ- 
ated with  "  bilateral  hyperplasia  "  of  the  adrenals,  have  been  collected  by 
Glynn.  Almost  all  these  are  cases  of  female  pseudohermaphroditism,  the 
patients  being  female  whose  external  genitalia  were  of  the  male  type.  In 
Crecchio's  case  the  masculine  resemblance  was  particularly  striking,  the 
patient  having  twice  contracted  gonorrhea  in  the  role  of  a  man. 

Retarded  Sexual  Development  Associated  With  Suprarenal  Hypo- 
plasia.—  Contrasted  with  such  observations  as  these  upon  the  influence 
of  suprarenal  overgrowth  upon  sexual  life,  it  is  of  interest  to  note  that  cases 
have  been  recorded  which  seem  to  show  that  retarded  sexual  development  is 
sometimes  associated  with  hypoplasia  or  atrophy  of  the  adrenals.  In 
Wiesel's  case,  for  example,  there  was  in  a  girl  of  eighteen  an  infantile 
condition  of  the  genitalia.  The  mammae  were  practically  absent,  the  nip- 
ples very  rudimentary,  there  were  no  axillary  hairs,  and  practically  none  on 
the  mons  veneris.  Autopsy  showed  a  striking  hypoplasia  of  the  adrenals. 
Similar  cases  have  been  reported  by  Kurakascheff,  Gilford,  Zander,  and 
others. 

THE  PINEAL  BODY 

General. —  This  structure,  which  is  looked  upon  as  representing  the 
vestigial  remains  of  a  primitive  third  or  dorsal  eye,  is  commonly  believed 
to  be  related  functionally  with  the  sexual  apparatus.  The  opinion  most 
generally  held  is  that  in  early  life  the  pineal  body,  like  the  thymus,  exerts 
an  inhibitory  effect  on  sexual  development.  This  view  is  based  very  largely 
upon  observations  in  certain  cases  of  pineal  tumor.  About  sixty-five  or 
seventy  authentic  cases  of  this  type  have  been  recorded,  according  to 
McCord. 

The  So-Called  Pineal  Syndrome. —  Only  about  10  per  cent  of  the 
entire  group,  however,  present  the  clinical  characters  making  up  the  "  pre- 
cocious macrogenitosomatic  pineal  syndrome."  The  latter,  according  to 
McCord,  "  is  characterized  by  (i)  overdevelopment  of  the  sex  organs,  both 
anatomic  and  functional;  (2)  precocity  of  mental  development;  (3)  general 
overgrowth  of  body  with  or  without  adiposity  —  the  whole  picture  being 
one  of  early  maturity."  The  syndrome  has  usually  been  explained  as  due 
to  a  hypopinealism,  on  the  theory  that  pineal  tumors  were  destructive  of 
functioning  pineal  tissue.  This  view  has  been  questioned  by  a  number  of 
investigators. 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  281 

Feeding  Experiments. —  The  most  striking  results  in  this  connection, 
however,  are  those  obtained  by  the  feeding  of  pineal  gland  tissue  under 
rigidly  controlled  conditions.  The  experiments  of  McCord,  made  on  guinea 
pigs,  showed  that  the  symptoms  usually  attributed  to  hypopinealism  "  may 
be  obtained  in  animals  by  supplying  an  increased  amount  of  pineal  substance 
by  feeding  or  injecting  pineal  preparations.  Such  administration  of  pineal 
substances  led  to  a  more  rapid  growth  of  body  than  normal,  and  determined 
an  early  sexual  maturity.  The  excess  in  rate  of  growth  was  most  pro- 
nounced (40.9  per  cent  excess  in  eleven  weeks)  in  young  animals  fed  with 
pineal  tissue  obtained  from  young  animals.  No  tendency  to  gigantism  has 
followed  pineal  administration.  After  maximum  size  was  attained,  pineal 
administration  appeared  to  be  ineffective.  Both  males  and  females  respond  . 
to  the  influence  of  pineal  substances  in  rate  of  growth,  but  the  response  has 
been  more  definitely  manifested  in  males"  (McCord). 

Results  of  Extirpation. —  The  results  of  extirpation  of  the  pineal 
body  by  a  perfected  technic,  as  reported  by  Dandy,  would  seem  to  indicate 
that  the  structure  is  of  negligible  importance,  none  of  the  supposedly  char- 
acteristic pineal  symptoms  being  produced.  Our  knowledge  of  the  function 
of  this  structure  is  confused  and  incomplete,  and  certainly  no  evidence  exists 
which  would  indicate  that  it  plays  an  indispensable,  or  even  an  important 
role,  in  the  body  economy. 

THE  THYMUS  GLAND 

Very  little  of  a  definite  nature  can  be  said  with  regard  to  the  relation  of 
the  thymus  to  the  reproductive  apparatus.  The  fact  that  the  gland  disap- 
pears at  about  the  time  of  puberty  has  led  some  to  believe  that  it  inhibits 
sexual  development.  Little  scientific  proof  for  this  view  has  been  brought 
forward.  On  the  other  hand,  there  is  good  reason  to  believe  that  the  gland 
is  in  some  way  concerned  with  body  growth.  Basch's  experiments  showed 
that  extirpation  of  the  thymus  is  followed  by  loss  of  weight  and  disturbances 
of  development  of  the  skeleton.  The  recent  work  of  Park  and  McClure, 
on  the  other  hand,  led  them  to  conclude  that,  in  dogs  at  least,  the  thymus 
body  is  unessential  to  life,  and  that  its  extirpation  exerts  no  influence  on 
growth  or  development. 

More  striking  are  the  remarkable  results  obtained  by  Gudernatsch  in 
feeding  thymus  and  thyroid  to  young  tadpoles.  When  thyroid  was  fed, 
there  was  a  pronounced  stimulation  of  differentiation,  so  that  the  tadpoles 
quickly  developed  into  young  frogs,  while  with  thymus,  on  the  other  hand, 
differentiation  was  not  accelerated,  but  growth  was,  so  that  instead  of  young 
frogs  the  thymus  experiments  yielded  large  tadpoles. 

The  removal  of  the  sexual  glands  in  animals,  according  to  Calzolari,  is 
followed  by  an  increase  in  the  size  of  the  thjmius,  Paton  likewise  found 
that  castration  retard  "^  the  normal  atrophy  of  the  thymus  in  guinea  pigs, 
and  that  thymectomy  performed  before  puberty  is  followed  by  an  increased 
growth  of  the  sexual  glands. 


282  MENSTRUATION  AND  ITS  DISORDERS 

THE  MAMMARY  GLAND 

It  has  long  been  known  that  a  close  physiological  relation  exists  between 
the  uterus  and  the  mammary  gland,  the  most  conspicuous  example  of  this 
correlation  of  function  being  the  phenomenon  of  lactation.  While  the  pri- 
mary cause  of  lactation  has  not  as  yet  been  definitely  established,  all  the 
best  evidence  of  recent  years  points  to  the  generative  organs  as  the  source 
of  the  impulse  giving  rise  to  the  process.  The  old  idea  that  the  function 
of  the  mammary  gland  is  in  some  way  dependent  upon  the  nervous  system 
would  seem  to  have  been  disproved  by  the  experiment  of  Ribbert,  who 
transplanted  the  mammary  gland  of  a  guinea  pig  beneath  the  animal's  ear, 
the  gland  developing  normally  and  producing  milk  when  the  animal  became 
pregnant. 

In  this  connection  the  work  of  Starling  is  of  interest.  This  observer 
injected  virgin  rabbits  with  extracts  made  from  various  portions  of  imma- 
ture rabbit  fetuses,  and  found  that  the  mammary  glands  of  the  injected 
animals  underwent  changes  similar  to  those  seen  in  the  glands  during 
normal  pregnancy.  He  concluded,  therefore,  that  the  hypertrophy  of  the 
glands  seen  during  pregnancy  is  produced  by  a  hormone  formed  in  the  body 
of  the  fetus,  and  that  the  occurrence  of  lactation  is  due  to  the  retrograde 
process  set  up  when  this  substance  is  withdrawn  by  the  expulsion  of  the 
fetus,  this  retrograde  process  showing  itself  in  the  formation  of  milk.  Foa 
has  reported  a  large  number  of  experiments  which  seem  to  corroborate  those 
of  Starling.  Halban,  on  the  other  hand,  states  that  the  function  of  the 
mammary  gland  is  due  to  an  internal  secretion  of  the  ovary,  except  during 
pregnancy,  when  this  function  is  temporarily  assumed  by  the  placenta, 
which  determines  the  occurrence  of  lactation. 

The  most  recent  investigation  of  the  subject  has  been  made  by  Frank 
and  Unger,  who  find  fault  with  the  results  of  both  Starling  and  Halban. 
Their  conclusions  are  as  follows  : 

"  I.  Intra-uterine,  prepuberty  and  puberty  growth  of  the  breasts  is 
directly  dependent  on  ovarian  function. 

"  2.  A  cyclical  change  in  the  virgin  breast  occurs  under  the  influence  of 
the  ovary. 

"  3.  Castration  does  not  cause  rapid  regression  of  the  cyclical  breast 
hyperplasia. 

"  4.  No  proof  has  been  offered  to  show  that  the  fetus  or  placenta  directly 
produces  growth  of  the  breast  in  pregnancy. 

"  5.  Evidence  points  to  the  fact  that  the  persistent  corpus  luteum  of  preg- 
nancy may  produce  this  breast  growth. 

"  6.  The  factors  which  favor  or  cause  the  persistence  of  the  corpus  luteum 
are  unknown. 

"  7.  Certain  evidence  (increase  of  the  breast  produced  by  hydatid  mole 
without  fetus,  chlorio-epithelioma)  makes  it  unlikely  that  the  fetus  is  at 
any  time  the  controlling  factor. 

"  8.  Nature's  process  is  more  complicated  than  the  simple  chemical  stim- 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  283 

ulus  assumed  by  Starling.  As  yet  hyperplasia  of  the  breasts  has  not  been 
produced  except  by  parabiosis,  which  does  not  explain  the  stimulus.  Pos- 
sibly the  influence  of  other  glands  of  internal  secretion  complicates  the 
problem. 

"  9.  Milk  secretion  is  no  evidence  of  quantitative  increase  in  breast  tissue. 

"  10.  Under  physiological  conditions  milk  secretion  sets  in  when  the 
ovarian  influence  is  removed,  in  the  newborn  after  birth;  in  the  puerpera 
as  the  corpus  luteum  of  pregnancy  regresses ;  sometimes  postoperatively 
after  castration  in  the  virgin  (if  the  breast  has  been  activated  by  the  corpus 
luteum  of  menstruation)." 

THE  PANCREAS 

Not  much  can  be  said  concerning  the  relation  of  the  ovaries  with  the 
pancreas.  Rebaudi,  working  in  Bossi's  clinic  at  Genoa,  has  reported  that 
he  has  been  able  to  demonstrate  a  functional  connection  between  the  ovary 
and  the  pancreas.  He  holds  that  the  islands  of  Langerhans  in  the  pancreas 
form  an  integral  part  of  a  great  system  of  organs  with  internal  secretions, 
and  that  when  the  function  of  the  corpus  luteum  in  the  ovary  is  diminished 
the  islands  of  Langerhans  show  a  marked  hypertrophy,  which  he  regards  as 
compensatory,  the  islands  evidently  doing  an  extra  amount  of  work. 
According  to  this  observer,  marked  changes  are  also  seen  after  removal  of 
the  ovaries  or  the  mere  destruction  of  the  corpora  lutea  alone.  He  accepts 
this  as  an  evidence  of  the  functional  importance  of  the  corpora  lutea  as  the 
chief  if  not  the  only  portion  of  the  ovary  concerned  in  the  production  of  an 
internal  secretion.  In  this  indirect  manner,  then,  he  arrives  at  conclusions 
essentially  similar  to  those  reached  by  Fraenkel  in  a  very  different  way. 


XXIV 
LITERATURE 

Adams.  A  Case  of  Precocious  Development  Associated  with  a  Tumor  of  the 
Left  Suprarenal  Body.     Trans.  Path.  See,  Lond.,  1905,  56,  208. 

Abler.  Zur  Physiologic  und  Pathologie  der  Ovarialfunktion.  Arch.  f.  Gyn., 
1912,  95,  349. 

Angel  et  Bouin.  Sur  les  homologies  et  la  signification  des  glandes  a  secre- 
tion interne  de  I'ovaire.     Compt.  Rend.  Soc.  de  Biol.,  Paris,  1909,  67, 

497. 
Aschner.     Ueber  Brunsitartige  Erscheinungen  nach  Subkutaner  Injektion  von. 

Ovarial  oder  Plazentarextract.     Arch.  f.  Gyn.,  1913,  99,  534. 

Bell.  Observations  on  the  Physiology  of  the  Female  Genital  Organs.  Brit. 
M.  J.,  1909,  I,  517. 

•  The  Sex  Complex;  a  Study  of  the  Relationships  of  the  Internal  Secre- 
tions to  the  Female  Characteristics  and  Functions  in  Health  and  Disease, 
New  York,  191 6. 


284  MENSTRUATION  AND  ITS  DISORDERS 

Below.  Glandula  Lutea  und  Ovarium  in  ihren  Verhalten  zu  den  Normalen 
Physiologischen  und  Pathologichen  Vorgangen  in  Weiblichen  Organ- 
ismus.     Alonats.  f.  Geb.  u.  Gyn.,  1912,  36,  679. 

Berkovitch.  De  I'obesite  d'origine  genitale  chez  la  femme  (rapports  avec 
I'adipose  douloureuse).     Paris,  1908.      (95  p.) 

BiEDL.     Innere  Sekretion.     1910. 

BucuRA.  Zur  Theorie  der  Inneren  Sekretion  des  Eierstocks.  Zentralb.  f. 
Gyn.,  1913,  ZJ,  1839. 

• Ueber  die  Bedeutung  der  Eierstocke   (Innere  Sekretion,  Geschlechts- 

charakter,  Pubert.,  u.  Klimak.  etc.)  Samml.  Klin.  Vortr.,  1909,  no. 
513-514.     (Gynak.  No.  187-188). 

Bulloch  and  Sequeira.  On  the  Relation  of  the  Suprarenal  Capsules  to  the 
Sexual  Organs.     Trans.  Path.  Soc.,  Lond.,  1905,  56,  189. 

Carmichael  and  Marshall.  On  the  Occurrence  of  Compensatory  Hyper- 
trophy in  the  Ovary.     J.  Physiol.,  1907-08,  36,  431. 

The  Correlation  of  Ovarian  and  Uterine  Functions.     Brit.  M.  J.,  1907, 

2,  1572. 
Chalfant.     Subcutaneous  Transplantation  of  Ovarian  Tissue.     Surg.,  Gyn. 

and  Obst,  1915,  21,  579. 
CoLOMBiNO.     Ueber    Transplantation    der    Ovarien    beim    Menschen.      Gyn. 

Rundsch.,  1914,  8,  705. 
Crecchio.     Ein  Fall  von  Hermaphroditismus.     Wien.  Med.  Presse,  1866,  7, 

Croom.  On  a  Case  of  Heteroplastic  Ovarian  Grafting,  Followed  by  Preg- 
nancy and  a  Living  Child  —  Who  is  the  Mother?  J.  Obst.  and  Gyn.  of 
Brit.  Emp.,  1906,  10,  197. 

Crowe,  Gushing  and  Homans.  Effects  of  Hypophysis  Transplantation  Fol- 
lowing Total  Hypophysectomy  in  Canines.  Quar.  J.  Exper.  Phys., 
1909,  2,  389. 

Gushing.     The  Pituitary  Body  and  its  Disorders.     1910. 

Daels.  On  the  Relationship  between  Ovaries  and  Uterus.  Surg.  Gyn.  and 
Obst,  1908,  6,  153. 

Davenport.  The  Transplantation  of  Ovaries  in  Chickens.  J.  Morphol., 
1911,  22,  III. 

Davidson.  Transplantart;ion  of  Ovary  in  Human  Being — 3  Cases.  Edinb.  M. 
J.,  1912,  9,  441. 

DoRAN.  Pregnancy  after  Removal  of  Both  Ovaries.  Jour.  Obst.  and  Gyn. 
of  Brit.  Emp.,  1902,  2,  i. 

Engstrom.  Ueberzahlige  Ovarien.  Mitteil.  der  Gyn.  Klinik  des  Prof.  Eng- 
strom,  1897,  I,  55. 

Erdheim  und  Stum  me.  Schwangerschaftsveranderung  der  Hypophyse. 
Miinch.  Med.  Wchnsch.,  1908,  55,  1202. 

Falta.     Die  Erkrankungen  der  Blutdriisen.       1913. 

Fellner.  Die  Wechselseitigen  Beziehungen  der  Innersekretorischen  Organe, 
insbesondere  zum  Ovarium.  Samml.  Klin.  Vortr.  (Leipz.),  1908,  n.f. 
no.  508,  Gyn.  no.  421. 

Fischera.  Sur  I'hypertrophie  de  la  glande  pituitaire  consecutive  a  la  castra- 
tion.    Arch,  de  Biol.,  1905,  43,  405, 

Findley.     Menstruation  without  Ovaries.     Tr.  Amer.  Gyn.  Soc,  1912,  yj,  82. 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  285 

FoA.     Sui  fattoriche  determinano  I'accrescimento  e  la  funzione  della  ghiandola 

mammaria.     Arch,  di  Fisiol.,  Firenze,  1907-8,  5,  520. 
Fraenkel.     Die  Funktion  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1903,  68,  438. 

Die  Physiologische  und  Pathologische  Beziehungen  zwischen  Ovarien 

und  Uterus.    Ztschr.  f.  Arztl.  Fortbild.  (Jena.)  1909,  6,  65. 
Frank.     Functions  of  Ovary.     Amer.  J.  Obst.,  191 1,  64,  297. 

AND  Unger.     An  Experimental  Study  of  the  Causes  which  Produce  the 

Growth  of  the  Mammary  Gland.     Arch.  Int.  Med.  191 1,  7,  812. 

AND  Rosenbloom.     Physiologically  Active  Substances  Contained  in  the 

Placenta  and  in  the  Corpus  Luteum.     Surg.  Gyn.  and  Obst.,  191 5,  21, 
646. 

Influence  of  Pituitary  Extracts  on  Genital  Tract.     Jour.  A.  M.  A.,  1919, 

73.  1764- 
Frohlich.     Ein  Fall  von  Tumor  der  Hypophysis  Cerebri  ohne  Akromegalie. 

Wien.  Klin.  Rundschau,  1901,  15,  883. 
Gellhorn.     Menstruation  ohne  Ovarien.     Centralb.  f.  Gyn.,  1907,  31,  1195. 
Glavecke.     Korperliche  und  Geistige  Veranderungen  im  Weiblichen  Korper 

nach  Kiinstlichen  Verlust  der  Ovarien  und  des  Uterus.     Arch.  f.  Gyn., 

1889,  34,  I. 
Glynn.     The  Adrenal  Cortex :  its  Rests  and  Tumors,  etc.    Quart.  J.  of  Med., 

1912,  5,  157. 
GoTSCH.     Relation  of  Pituitary  Gland  to  Female  Generative  Organs.     Surg., 

Gyn.  and  Obst,  19 17,  25,  229. 
GooDALL  and  Conn.     The  Relation  of  the  Thyroid   Gland  to  the   Female 

Generative  Organs.     Surg.,  Gyn.  and  Obst.,  191 1,  12,  457. 
Gordon,   A.     Nervous    and    Mental    Disturbances    Following    Castration    in 

Women.     Jour.  A.  M.  A.,  1914,  62,,  1345. 
Gordon,  S.     Tv/o  Pregnancies  After  Removal  of  Both  Ovaries  and  Tubes.  Am. 

Gyn.  and  Obst.  J.,  1896,  9,  28. 
von  Graff.     Schilddriise  und  Genitale.     Arch.  f.  Gyn.,  1914,  102,  109. 

und  Novak.     Basedow  und  Genitale.     Arch.  f.  Gyn.,  1914,  102,  18. 

Graves.     Practical  Aspects  of  the  Ovarian  Secretions,     N.  Y.  State  J.  Med., 

1916,  16,  394. 

Transplantation  and  Retention  of  Ovarian  Tissue  after  Hysterectomy. 

Surg.,  Gyn.  and  Obst.,  1917,  25,  315. 

Guthrie  and  Lee.     Ovarian  Transplantation.     Jour.  A.  M.  A.,  191 5,  64,  1823. 
Halban.     Ueber  den  Einfluss  des  Ovariums  auf  die  Entwickelung  des  Geni- 
tales.     Monats.  f.  Geb.  u.  Gyn.,  1900,  12,  498. 

Die  Innere  Sekretion  von  Ovarium  und  Plazenta  und  ihre  Bedeutung 

fiir  die  Funktion  der  Milchdriise.     Arch.  f.  Gyn.,  1905,  75,  353. 

Herman.     tJber  eine  Wirksame  Substanz  im  Eierstocke  und  in  der  Plazenta. 

Monats.  f.  Geb.  u.  Gyn.,  1915,  41,  i. 
Herring.     Contribution    to    Comparative    Physiology    of    Pituitary    Body. 

Quart.  J.  Exper.  Phys.,  1908,  i,  261. 
IscovEsco.     Lipoides  homostimulants  de  I'ovaire  et  du  corps  jaune.     Rev.  de 

Gynec.  et  de  Chir.  Abd.,  Par.,  1914,  22,  161. 
Knauer.     Zur  Ovarien  Transplantation.     Zentralb.   f.   Gyn.,   1898,  22,  201. 

Also  Arch.  f.  Gyn.,  1900,  60,  322. 


286  MENSTRUATION  AND  ITS  DISORDERS 

LoEB.     Factors  in  Growth  and  Sterility  of  Mammalian  Ovary.     Science,  ,1917, 

45,  591- 

Relation  of  Ovary  to  Uterus  and  Mammary  Gland.     Surg.  Gyn.  and 

Obst,  1917,  25,  300. 
LoWY  UND  RiCHTER.     Zur  Frage  nach  dem  Einfluss  der  Kastration  auf  den 

Stoffwechsel.     Zentralb.  f.  Physiologie,  1902  (quoted  by  Biedl). 
Marine.     Thyroid  Gland  in  Relation  to  Gynecology  and  Obstetrics.     Surg., 

Gyn.  and  Obst.,  1917,  25,  272. 
Marshall.     The  Physiology  of  Reproduction.     London,  1910. 
Martin.     Ovarian  Transplantation.     Surg.,  Gyn.  and  Obst.,  1915,  21,  568. 

Progress  in  Study  of  Ovarian  Transplantation  and  Ovarian  Secretion. 

Surg.,  Gyn.  and  Obst.,  1917,  25,  336. 

Ovarian  Transplantation  in  Lower  Animals  and  Women.     Am.  J.  Obst., 

1911,64,303.       , 

Mauclaire  et  Eisenberg.     Les  ovaries  surnumeraires.     Arch.  Gen.  de  Chir., 

1911,  7>  755- 
Mayer.     Ueber  den  Einfluss  des  Eierstocks  auf  das  Wachstum  des  Uterus, 

etc.     Zeitsch.  f.  Geb.  u.  Gyn.,  191 5,  yp,  279. 

Ueber  die  Beziehungen  zwischen  Keimdriisen  und  Hypophysis.     Arch. 

f.  Gynak.,  1910,  90,  600. 

Mayo.     Conservation  of  the  Menstrual  Function.     Jour.  A.  M.  A.,  1920,  74, 

1685. 
McCoRD.     Pineal  Gland  and  Sex  Development.     Jour.  A.  M.  A.,  1915,  65,  517. 
Morley.     Is  there  any   Clinical  or  Experimental   Proof  that  Ovary  has   an 

Internal  Secretion.     Am.  J.  Obst,  191 1,  64,  298. 

Preparation  and  Standardization  of  Ovarian  and  Placental  Extracts. 

Surg.,  Gyn.  and  Obst.,  1917,  25,  324. 

Morris.     The  Ovarian  Graft.     N.  Y.  Med.  J.,  1895,  62,  436. 

Neu.     Zur  Frage  der  Sogenannten  Pseudomenstruation.    Zentralb.  f.  Gynak., 

1911,  35»  392. 
Novak,  E.     The  Hormone  Theory  and  the  Female  Generative  Organs.    Surg., 

Gyn.  and  Obst.,  1909,  9,  344. 
Novak,  J.     Ueber  die  Bedeutung  des  Weiblichen  Genitales  fiir  den  Gesamt- 

organismus,  etc.     H.  Nothnagel,  Spez.  Path,  und  Therapie,  Suppl.  6, 

539- 

Ueber   den   Einfluss   der   Nebennierenausschaltung   auf   das    Genitale. 

Arch.  f.  Gyn.,  1914,  loi,  36. 
Ogorek.     Funktionierendes  Ovarium  bei  Nie  Menstruierter  Frau.  Zentralb. 

f.  Gyn.,  191 1,  35,  1236. 
Okintschitz.     Ueber   die    Gegenseitigen    Beziehungen    einiger    Driisen    mit 

Innerer  Sekretion.     Arch.  f.  Gyn.,  1914,  102,  333. 
Ott  and  Scott.     Note  on  the  Galactagogue  Action  of  the  Thymus,  Corpus 

Luteum  and  the  Pineal  Body.    Month.  Cycl.  and  M.  Bull.,  191 1,  4,  99. 
Pappenheimer.     Thymus  Gland  and  its  Possible  Relation  to  Female  Genital 

Tract.     Surg.,  Gyn.  and  Obst,  1917,  25,  276. 
Park  and  McClure.     Results  of  Extirpation  of  Thymus  in  Dogs.    Am.  J.  Dis. 

Children,  1919,  18,  317. 
Pfister.     Die  Wirkung  der  Castration  auf  den  Weiblichen  Organismus.  Arch. 

f.  Gyn.,  1898,  56,  583. 


MENSTRUATION  AND  THE  ENDOCRIN  GLANDS  287 

Pool.     Relation  of  Parathyroid  System  to  Female  Genital  Apparatus.     Surg., 

Gyn.  and  Obst.,  1917,  25,  260. 
Rebaudi.     Eierstock,  Corpus  Luteum,  und  Langerhans'che  Zellenseln.     Zen- 

tralb.  f.  Gyn.,  1908,  32,  1332. 
RoTHROCK.     The  Association  of   Obesity  in  Women  with  Amenorrhea   and 

Sterility.     St.  Paul  M.  J.,  1908,  10,  70. 
SCHICKELE.     Beitrage  zur  Physiologic  und  Pathologie  der  Ovarien.     Arch.  f. 

Gyn.,  1912,  97,  409. 
Sehrt.     Zur    Thyreogenen    Atiologie    der    Hamorrhagischen    Metropathien. 

Miinch.  Med.  Wchnsch.,  1913,  60,  961. 
Smith  and  Wood.     An  Accessory  Ovary.     N.  Y.  Med.  J.,  1916,  104,  835. 
Steinach.     Willkiirliche  Umwandlung  von  Saugetiermannchen  in  Tiere,  etc. 

Pfliigers  Arch.,  1912,  144,  71. 

Geschlechtstrieb  und  Echte  Sekundare  Geschlechtsmerkmale  als  Folge 

der    Innersekretorischen    Funktion    der    Keimdriisen.       Zentralb.     f. 
Physiol.,  1910,  24,  551. 

Storer.     On  Ovarian  Transplantation.     Bost.  M.  and  S.  J.,  191 5,  172,  97. 
Tandler  und  Gross.     Einfluss  der  Kastration  auf  den  Organismus.     Wien. 

Klin.  Wchnsch.,  1907,  20,  1596. 
Thumin.     Geschlechtscharaktere  und  Nebenniere  in  Correlation.     Berl.  Klin. 

Wchnsch.,  1908,  46,  103. 

Beziehungen     zwischen     Hypophysis    und    Eierstocken.     Berl.     Klin. 

Wchnsch.,  1909,  46,  631. 

Tuffier.     Transplantation  of  Ovaries.     Surg.,  Gyn.  and  Obst,  1915,  20,  30. 
Vincent.     Experimental  and  Clinical  Evidence  as  to  Influence  Excited  by 
Adrenal   Bodies  upon  Genital   System.     Surg.,   Gyn.   and   Obst.,    1917, 

25,  94- 

Wallin.  Postclimacteric  Uterine  Hemorrhage  Due  to  Relative  Hypothyroid- 
ism.    Jour.  A.  M.  A.,  1908,  51,  2157. 

Whitehouse.  The  Autoplastic  Ovarian  Graft  and  its  Clinical  Value.  Clin. 
J.,  London,  1913,  42,  107. 

WiESEL.  Zur  Pathologischen  Anatomie  der  Addisonschen  Krankheit.  Zeitsch. 
f.  Heilk.,  1903,  24,  257. 


CHAPTER  XXV 
RECIPROCAL  RELATIONS   OF  MENSTRUATION  AND  VARIOUS   DISEASES 

Introduction. —  Even  granting  that  menstruation  in  the  normal, 
healthy  woman  has  practically  no  effect  on  her  activities,  certainly  it  cannot 
be  denied  that  when  abnormal,  and  especially  when  associated  with  great 
pain,  its  effect  on  the  general  health  of  the  woman  may  be  very  great.  It 
is  not  surprising,  therefore,  that  menstruation  may  exert  important  and 
interesting  effects  upon  the  course  of  many  diseases  to  which  the  woman 
may  fall  victim.  Conversely,  many  diseases  modify  the  regular  rhythmic 
course  of  the  woman's  menstrual  life  in  an  equally  important  manner. 

It  is  surprising  how  little  attention  has  been  paid  to  these  two  facts  by 
almost  all  authors,  including  those  of  large  systems  of  medicine.  I  have 
therefore  thought  that  it  might  be  of  value  to  collect  in  one  chapter  what 
has  been  learned  and  written  concerning  this  much  neglected  subject. 

TUBERCULOSIS  AND  MENSTRUATION 

General  Considerations. —  Owing  to  the  extreme  frequency  of  tuber- 
culosis, especially  of  the  pulmonary  form,  the  relation  of  menstruation  to 
this  disease  is  a  subject  of  great  importance.  While  certain  facts  concern- 
ing this  relationship  are  rather  generally  recognized,  there  are  others  con- 
cerning which  there  is  as  yet  no  unanimity  of  opinion.  The  subject  may 
be  logically  discussed  under  two  heads,  as  follows :  ( i )  the  influence  of 
tuberculosis  upon  menstruation;  and  (2)  the  influence  of  menstruation 
upon  the  course  of  tuberculosis. 

The  Influence  of  Tuberculosis  Upon  Menstruation. —  Amenorrhea 
More  Common  Than  Menorrhagia. —  When  a  disturbance  of  menstrua- 
tion is  associated  with  tuberculosis,  it  is  most  likely  to  be  amenorrhea. 
Occasionally,  however,  menorrhagia  may  be  observed  instead,  while  dys- 
menorrhea is  not  by  any  means  a  rare  finding.  The  relative  frequency  of 
amenorrhea  and  excessive  menstruation  may  be  gleaned  from  the  following 
table  by  Macht,  based  on  a  study  of  1600  histories  from  the  Phipps  Tuber- 
culosis Clinic  at  the  Johns  Hopkins  Hospital : 

( 1 )  Regular  menstruation 

(2)  Amenorrhea 

(3)  Irregular  menstruation 

(4)  Menorrhagia 

(5)  Pregnant  or  lactating , 

(6)  In  menopause,  artificial  or  otherwise 

288 


Per 

cent 

51 

6 

27 
8 

4 

3 
3 
6 

4 
3 

4 
8 

RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES      289 

Influence  of  the  Age  of  the  Patient. —  Macht  believes  that  the  age 
of  the  patient  is  a  factor  of  great  importance  in  determining  the  regularity 
of  the  menses,  and  that  "  it  is  as  rare  to  find  the  menstruation  suppressed 
in  patients  of  thirty-five  years  or  over  as  it  is  to  find  it  present  in  patients 
below  twenty  years."  Of  the  amenorrheic  patients,  Macht  finds  that  32.5 
per  cent  were  under  twenty,  and  39.0  per  cent  between  twenty  and  thirty, 
making  a  total  of  nearly  three  fourths  below  the  age  of  thirty. 

Influence  of  tpie  Stage  of  the  Disease. —  Another  factor  of  great 
importance  —  perhaps  more  important  than  the  age  of  the  patient  —  is  the 
stage  of  the  disease.  Analysis  of  a  large  series  of  cases  by  Margarete 
Friedrich  showed  that,  of  patients  suffering  with  the  first  or  earliest  stage 
of  tuberculosis,  45  per  cent  were  amenorrheic ;  in  more  advanced  forms,  the 
proportion  was  increased  to  64  per  cent,  and,  in  even  later  stages  of  the 
disease,  fully  85  per  cent  showed  amenorrhea.  These  figures  are  much 
like  those  of  Welch,  who  found  amenorrhea  in  11. 9  per  cent  of  early  cases; 
in  23.7  per  cent  of  those  with  two  lobes  diseased;  and  in  62.5  per  cent  of 
the  most  advanced  cases. 

Menstrual  Disturbances  Not  Usually  Dependent  on  Local 
Lesions  in  Pelvis. —  These  various  statistics,  and  others  which  might  be 
quoted  to  the  same  effect,  would  seem  to  dispose  of  the  statement  made  by 
Veit  at  the  Fourteenth  Gynecological  Congress  in  Munich  in  191 1  that,  gen- 
erally speaking,  menstruation  and  ovulation  are  not  influenced  during  the 
course  of  tuberculosis  unless  there  are  local  pathological  alterations  in  tubes 
and  ovaries.  The  latter,  he  says,  may  be  assumed  to  be  present  if  a  con- 
sumptive woman  misses  her  menses  and  if  pregnancy  can  be  excluded.  He 
admits,  however,  that  amenorrhea  can  occasionally,  though  rarely,  occur 
without  local  lesions  in  cases  of  advanced  pulmonary  tuberculosis,  with 
marked  debility. 

The  statements  of  Veit  were  vigorously  opposed  at  the  Congress,  espe- 
cially by  Fraenkel  and  Gottschalk.  They  are  certainly  not  in  keeping  with 
my  own  experience,  nor,  to  judge  from  reports  in  the  literature,  with  the 
experience  of  others.  For  example,  the  figures  of  Friedrich,  which  have 
been  quoted  above,  were  based  on  200  cases  in  which  the  possibility  of 
local  tuberculous  disease  in  the  pelvic  organs  seems  to  have  been  definitely 
excluded.  There  can  be  little  doubt,  therefore,  that  amenorrhea  is  an 
extremely  frequent  concomitant  of  even  early  tuberculosis  and  that  it  is 
even  more  frequent  in  late  stages  of  the  disease. 

While  Veit  is  unquestionably  wrong  in  assuming  that  amenorrhea  in 
tuberculosis  is  always  due  to  local  involvement  of  the  pelvic  organs,  the 
possibility  of  such  involvement  should  be  borne  in  mind  in  every  case  of 
pulmonary  tuberculosis.  In  a  recent  paper  Schiffman  calls  attention  to  the 
frequency  with  which  amenorrhea,  when  associated  with  a  hypoplastic 
uterus,  is  In  reality  found  on  microscopical  examination  to  be  due  to  tuber- 
culous disease  of  the  uterus  or  tube.  In  addition  to  two  cases  of  his  own, 
he  mentions  three  report-ed  by  FerronI,  in  which  tuberculosis  was  found  in 


290  MENSTRUATION  AND  ITS  DISORDERS 

the  corpus  uteri  of  three  virgins,  from  12  to  14  years,  who  were  curetted 
for  intractable  uterine  hemorrhage.  With  tubal  or  uterine  tuberculosis, 
menorrhagia  is  more  frequent,  in  my  experience,  than  amenorrhea. 

Explanation  of  Amenorrhea  in  Tuberculosis. —  As  to  the  exact 
mechanism  of  amenorrhea  in  tuberculosis,  little  of  a  definite  nature  can  be 
stated.  To  explain  it  as  due  to  the  associated  anemia  is  merely  begging 
the  question.  Hofbauer  and  Thaler  state  that  tuberculous  patients  with 
amenorrhea  run  less  favorable  courses  than  those  in  whom  menstruation  is 
normal.  They  explain  this  by  the  fact  that  tubercle  bacilli  thrive  on  lipoid 
containing  media,  and  that  removal  of  the  ovaries  or  cessation  of  their 
function  brings  about  an  excess  of  lipoids  in  the  blood.  In  other  words, 
the  tubercle  bacilli  cause  an  inhibition  of  ovarian  secretion  and  thereby  a 
lipoidemia,  which  is  favorable  for  their  own  growth.  The  work  of  Fried- 
rich,  however,  throws  serious  doubt  upon  the  views  of  Hofbauer  and 
Thaler. 

Practical  Importance  of  Amenorrhea  in  Tuberculosis. —  From 
a  practical  point  of  view,  the  amenorrhea  so  often  observed  in  early  phthisis 
is  exceedingly  important.  I  have  on  a  number  of  occasions  been  led  to 
suspect  incipient  lung  lesions  in  girls  who  consulted  me  merely  on  account 
of  amenorrhea.  If  cough  is  present,  and  especially  if  there  be  a  rapid 
pulse  rate  and  even  a  slight  evening  fever,  the  diagnosis  of  tuberculosis 
admits  of  little  question.  For  this  reason  the  possibility  of  early  tubercu- 
losis should  always  be  borne  in  mind  in  seeking  for  the  cause  of  amenor- 
rhea, especially  in  young  girls. 

A  second  point  worthy  of  remembrance  is  that  amenorrhea  in  consump- 
tion may  be  due  to  the  change  of  climate  which  many  patients  are  called 
upon  to  make  in  the  treatment  of  the  malady. 

Finally,  attention  may  be  called  to  the  very  prevalent  belief  among  the 
laity  that  amenorrhea  is  a  source  of  great  danger  to  the  girl,  in  that  it  may 
cause  her  to  "  go  into  decline,"  i.  e.,  that  she  may  develop  tuberculosis.  It 
need  scarcely  be  said  that  amenorrhea  in  itself  exerts  no  such  effect.  The 
belief  is  obviously  to  be  attributed  to  the  frequent  association  of  amenor- 
rhea and  early  phthisis,  suggesting  to  the  superficial  observer  a  possible 
causative  role  on  the  part  of  the  amenorrhea. 

Menorrhagia  in  Tuberculosis. —  Many  years  ago  (1887)  Handford 
called  attention  to  the  fact  that  menorrhagia  at  the  beginning  of  men- 
strual life  is  indicative  of  a  predisposition  to  tuberculosis,  and  that  in  fam- 
ilies with  a  hereditary  tendency  to  the  disease,  the  females  are  apt  tO'  show 
early  and  free  menstruation.  While  much  less  frequent  than  amenorrhea, 
menorrhagia  is  observed  in  a  considerable  proportion  of  cases  of  tuber- 
culosis. There  are  some,  as  a  matter  of  fact,  who  look  upon  excessive 
menstruation  as  more  frequent  than  amenorrhea.  Rosenstrauss,  for  ex- 
ample, found  that  among  36  patients  with  tuberculosis,  5  showed  no  change 
in  the  character  of  the  menses,  2  a  decrease  in  the  menstrual  flow,  while 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     291 

29  stated  that  with  the  onset  of  the  king  affection  there  was  an  increase  in 
the  amount  of  the  menstrual  flow. 

The  table  of  Macht,  given  above,  shows  that  menorrhagia  was  present 
in  4.6  per  cent  of  his  cases.  This  would  seem  to  me  to  represent  more 
nearly  the  correct  proportion.  ]\lacht  states  that  menorrhagia,  when  it 
does  occur,  is  an  early  symptom  of  tuberculosis,  preceding  the  amenor- 
rhea which  is  more  commonly  observed  in  association  with  the  disease. 
When  menorrhagia  occurs  in  the  later  stages  of  the  disease,  one  should 
always  bear  in  mind  the  possibility  of  local  tuberculous  disease  in  the  pelvic 
organs. 

Dysmenorrhea  in  the  Tuberculous. —  The  paper  of  Eisenstein  and 
Hollos,  published  in  1908,  called  attention  forcibly  to  the  frequency  with 
which  dysmenorrhea  is  associated  with  tuberculosis.  What  is  more,  these 
authors  endeavored  to  show  that  the  dysmenorrhea  is  the  direct  result  of  a 
general  intoxication  of  the  organism  with  the  toxins  of  the  tubercle  bacilli. 
These  poisonous  products,  they  say,  bring  about  metabolic  disturbances 
during  the  years  of  puberty,  and  frequently  infantilism  of  the  genital  appar- 
atus is  the  result. 

As  a  further  evidence  of  the  probable  tuberculous  origin  of  dysmenor- 
rhea in  many  instances,  Eisenstein  and  Hollos  draw  attention  to  the  remark- 
able results  of  antituberculosis  measures  in  these  cases,  their  own  plan 
being  the  administration  of  tuberculin.  Of  70  cases  of  dysmenorrhea,  2y 
were  found  to  be  tuberculous,  tubercle  bacilli  being  found  in  23,  and  being 
occult  in  4.  Twenty-two  of  these  cases  were  treated  with  tuberculin  and 
16  were  entirely  cured.  The  result  in  those  cases  showing  amenorrhea 
were  fully  as  remarkable. 

Grafenburg's  experience  corroborates  the  assumption  that  dysmenorrhea 
has  an  underlying  tuberculous  basis  in  many  cases.  He  found  tubercu- 
lous lesions  at  autopsy  in  three  young  women  who  had  been  treated  for 
dysmenorrhea.  In  another  case  of  the  kind,  the  severe  abdominal  pain 
compelled  laparotomy,  which  revealed  tuberculous  lesions  in  the  pelvic 
organs.  He  alludes  to  the  case  of  Pfannenstiel,  in  which  rapid  miliary 
tuberculosis  in  the  abdomen  followed  dilation  of  the  cervix  by  means  of  a 
laminaria  tent  for  the  relief  of  dysmenorrhea. 

Grafenberg  himself  obtained  positive  results  with  the  tuberculin  test  in 
21  of  30  patients  who  had  applied  for  relief  from  primary  dysmenorrhea. 
The  test  was  always  negative  in  the  cases  of  secondary  dysmenorrhea. 
With  the  primary  form,  he  says,  the  genitalia  are  always  defectively  de- 
veloped. In  1 1  of  his  cases  there  was  also  a  local  reaction  in  the  genitalia. 
These  results  suggest  that  the  defective  development  of  the  genital  organs 
is  the  consequence  of  a  tuberculous  process  in  the  pelvic  organs  during 
childhood,  this  process  subsequently  undergoing  healing.  Dysmenorrhea 
in  these  cases  is  explained  by  the  periodically  recurring  menstrual  hypere- 
mia. Among  others  who  have  emphasized  the  relation  between  tubercu- 
losis and  dysmenorrhea  are  Diepgen  and  Schroder. 


292  MENSTRUATION  AND  ITS  DISORDERS 

Whether  this  relation  is  as  direct  as  some  would  have  us  believe  it  is  as 
yet  difficult  to  say.  There  can  be  no  question,  however,  as  to  the  great 
frequency  of  dysmenorrhea  in  tuberculosis.  In  the  later  stage  of  the 
disease  the  menstrual  pain  would  seem  to  be  explaniable  by  the  greater 
susceptibility  to  pain  which  accompanies  the  lowered  vitality  of  this  stage. 

In  any  case  of  dysmenorrhea  in  which  a  tuberculous  etiology  is  suspected 
there  is  a  strong  indication  for  treatment  by  fresh  air,  sunshine,  rest,  good 
food,  and,  in  properly  selected  cases,  by  means  of  tuberculin. 

Influence  of  Menstruation  Upon  Tuberculosis. —  General  Consid- 
ERATioxs. —  If  the  old  wave  theory  of  menstruation,  as  first  enunciated  by 
Goodman  and  later  by  Stephenson  and  Jacobi,  were  correct,  it  would  be 
easy  indeed  to  understand  that  menstruation  must  exert  a  considerable  influ- 
ence on  the  course  of  tuberculosis.  According  to  this  theory,  it  will  be 
recalled  (Chapter  VIII),  the  menstrual  periods  are  accompanied  by  a  height- 
ening of  the  metabolic  activity  and  an  increase  in  some  of  the  body  processes. 

As  was  stated  in  a  preceding  chapter,  the  evidence  furnished  by  recent 
investigations  tends  to  disprove  the  "menstrual  wave  theory"  (see 
Chapter  VIII).  The  fact  remains,  nevertheless,  that  each  menstrual  period, 
even  in  the  normal  woman,  may  entail  sufficient  physical  and  psychic  un- 
rest to  project  it  above  the  even  tenor  of  her  daily  life.  It  can  also  be 
readily  understood  that  the  monthly  disturbance  of  menstruation  will  be 
all  the  greater  when  the  woman's  susceptibility  is  increased  by  such  a 
serious  malady  as  tuberculosis. 

Historical. — That  the  menstrual  periods  may  influence  the  course  of 
pulmonary  tuberculosis  has  been  known  for  many  years.  Indeed,  men- 
tion was  made  of  this  fact  by  Laennec  in  1879,  and  even  earlier  by  Raci- 
borski  (1868).  The  first  work  in  which  this  subject  was  considered  in  an 
exhaustive  way  was  that  of  Daremberg,  in  1880.  In  1899  Neuman,  in  a 
paper  before  the  Tuberculosis  Congress,  in  Berlin,  called  attention  to  the 
fact  that,  at  the  menstrual  periods,  patients  suffering  with  pulmonary  tuber- 
culosis exhibit  a  rise  of  temperature  and  an  exacerbation  of  the  lung  symp- 
toms. In  this  way,  he  says,  the  diagnosis  of  an  otherwise  latent  tubercu- 
losis may  be  made  possible. 

The  same  year  saw  the  publication  of  the  first  of  Turban's  papers  on  the 
subject.  The  credit  of  emphasizing  the  importance  of  the  menstrual  in- 
fluence upon  the  body  temperature  of  consumptives  is  due,  perhaps  chiefly, 
to  this  author.  In  a  second  more  elaborate  paper,  presented  before  the 
Twenty-fifth  Medical  Congress  in  Vienna  in  1908,  he  distinguishes  the 
several  types  of  fever  which  may  be  exhibited  by  consumptive  women  in 
association  with  menstruation,  as  follows:  (i)  premenstrual;  (2)  inter- 
menstrual; (3)  postmenstrual ;  (4)  menstrual;  (5)  menstrual  remissions. 

Premenstrual  Fever  in  Consumptives. —  Of  these  forms  of  fever 
the  most  frecjuent  is  the  premenstrual,  which  is  found  in  fully  73  per  cent 
of  the  cases,  according  to  Turban.  Others  consider  its  frequency  much 
lower,  Riebold  giving  it  as  only  12  per  cent.     It  is  important  to  bear  in 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     293 

mind  that  this  premenstrual  rise  is  purely  a  relative  one.  If  it  occurs  in  pa- 
tients with  very  incipient  tuberculosis,  who  have  been  having  no  fever  at 
other  times,  it  is  shown  by  a  slight  elevation  of  temperature,  for  from  a 
few  days  to  a  week  before  the  onset  of  menstruation,  to  perhaps  99.5°  F. 
or  100°  F.  If,  on  the  other  hand,  the  patient  has  been  habitually  running 
a  slight  fever,  the  approach  of  menstruation  is  characterized  by  an  exacer- 
bation. 

Cornet  also  speaks  of  a  premenstrual  rise  of  temperature  which  he  says 
occurs  in  two  thirds  of  the  cases  of  tuberculous  disease  in  the  female,  add- 
ing that  it  has  no  influence  on  the  course  of  the  disease,  but  has  a  certain 
value  in  diagnosis. 

Frank  says  that  the  increase  of  temperature  is  to  be  seen  only  on  taking 
the  temperature  per  rectum,  but  this  is  not  true,  since  all  of  Turban's  ob- 
servations were  based  on  temperature  readings  taken  for  ten  minutes  by 
mouth. 

Kraus  also  found  the  premenstrual  elevation  of  temperature  in  two 
thirds  of  his  tuberculous  cases.  Its  duration,  he  says,  varies  from  ten  days 
to  two  weeks,  and  it  gives  rise  to  no  symptoms.  Sometimes  it  is  accom- 
panied by  an  increase  of  rales,  as  after  a  tuberculin  injection. 

The  significance  of  premenstrual  fever,  as  far  as  the  course  of  the  dis- 
ease is  concerned,  is  usually  not  great.  It  is,  however,  of  some  pro'gnostic 
importance,  a  very  marked  premenstrual  elevation  of  fever  being  consid- 
ered unfavorable,  while  slight  fever  at  that  time  is  usually  indicative  of 
favorable  progress  of  the  tuberculous  disease. 

PosTMENSTRUAL  Fever. —  The  postmeustrual  type  of  fever,  according 
to  Turban,  is  often  the  expression  of  an  actual  exacerbation  of  the  lung 
trouble,  and  hence  is  usually  a  sign  of  bad  import. 

Other  Types  of  Fever  in  Consumption. —  The  other  types  are  much 
rarer  in  their  occurrence.  The  intermenstrual  variety  of  fever  was  de- 
scribed by  Van  Voorn veldt  in  1905.  In  the  single  case  which  he  reported 
the  rise  of  temperature  took  place,  not  at  the  menstrual  periods,  but  reg- 
ularly in  the  intermenstrual  periods  instead.  This  fact  immediately  sug- 
gests that  the  phenomenon  may  correspond  with  the  peculiar  intermen- 
strual pain  (mittelschmerz)  of  which  some  patients  complain,  and  which 
by  most  authors  is  now  looked  upon  as  due  to  the  occurrence  of  ovulation 
at  this  time  (Chapter  XXI).  This,  at  any  rate,  was  Van  Voornveldt's 
explanation  of  "  febris  intermenstrualis." 

Influence  of  Menstruation  Upon  Subjective  Symptoms  of  the 
Disease. — ■  The  influence  of  menstruation  upon  the  subjective  symptoms 
of  tuberculosis  is  in  some  cases  slight,  in  others  quite  marked.  The  cough 
is  apt  to  be  much  more  troublesome  at  the  time  of  the  periods.  In  the 
more  advanced  cases,  especially,  dyspnea  is  often  much  exaggerated  and 
may  be  quite  distressing.  Rales  may  become  more  abundant,  and  there 
may  be  every  evidence  of  an  actual  exacerbation  of  the  disease. 

While  the  extra  discomfort  thus  produced  may  last  only  through  the 


294  MENSTRUATIOiM  AND  ITS  DISORDERS 

menstrual  period,  it  is  inconceivable  that  such  periodic  exacerbations  should 
not  exert  an  unfavorable  influence  upon  the  general  course  of  the  disease. 
Daremberg  called  attention  to  the  fact  that  even  in  those  cases  in  which 
amenorrhea  is  present  a  similar  flareup  of  symptoms  can  still  occur  at 
intervals  corresponding  to  the  menstrual  cycle. 

The  symptom  of  tuberculosis  which  is  of  greatest  importance  in  connec- 
tion with  menstruation  is  hemoptysis.  A  considerable  number  of  cases  have 
been  reported  in  which  periodic  hemoptysis  occurs  in  association  with  the 
menstrual  periods.  Macht  believes  that  they  are  not  nearly  so  rare  as  they 
have  usually  been  considered  to  be,  and  states  that  at  least  fifteen  patients 
among  those  treated  at  the  Phipps  Tuberculosis  Dispensary  of  the  Johns 
Hopkins  Hospital  gave  a  history  of  hemoptysis  occurring  with  the  men- 
strual periods.  Occasionally  these  pulmonary  hemorrhages  may  occur  in 
the  absence  of  the  normal  menstrual  flow,  which  they  apparently  replace. 
They  then  represent  instances  of  genuine  vicarious  menstruation  (see 
Chapter  XXni). 

TYPHOID  FEVER  AND  MENSTRUATION 

Effect  of  Typhoid  on  Menstruation. —  General  Considerations. — 
It  can  not  be  stated  that  authors  are  agreed  as  to  the  effect  exerted  by 
typhoid  fever  on  the  menstrual  process.  There  are  some,  such  as  Briere 
de  Boismont  and  Friesinger,  who  assert  that  the  effect  is  a  powerful  one 
and  is  exerted  throughout  the  course  of  the  disease.  Others,  like  Peroud 
and  Slavjanski,  consider  the  influence  of  typhoid  on  menstruation  much 
less  noteworthy,  asserting  that  it  is  noticeable  only  at  the  very  beginning 
of  the  disease. 

Menstruation  Usually  Diminished  or  Absent, —  According  to 
Osier  and  McCrae,  menstruation  as  a  rule  ceases  during  typhoid,  although 
it  is  not  uncommon  for  it  to  occur  at  the  onset  of  the  disease.  When  it 
does  SO',  the  intermenstrual  interval  is  apt  to  be  shorter  than  normal. 
These  authors  found  that  menstruation  was  present  in  ii  of  483  patients 
during  the  course  of  typhoid  fever.  It  was,  however,  never  profuse,  as 
has  been  reported  by  some. 

Significance  of  Uterine  Bleeding  in  the  Hemorragic  Type  of 
Typhoid. —  In  the  hemorrhagic  type  of  the  disease,  uterine  bleeding  may 
occur.  In  patients  with  early  and  perhaps  unsuspected  pregnancy,  it  is  not 
always  easy  to  diagnose  between  the  bleeding  of  early  abortion  and  bleeding 
of  menstrual  character.  Owing  to  the  tendency  of  such  febrile  diseases 
as  typhoid  to  cause  abortion,  this  possibility  should  be  borne  in  mind  when 
uterine  bleeding  occurs  during  the  period  of  onset  of  the  disease,  especially 
if  the  bleeding  be  at  all  profuse. 

Variations  in  Effect  of  Typhoid  on  Menstruation, —  Curschman 
states  that  menstruation  often  occurs  during  the  early  days  of  typhoid 
fever,  and  that  it  may  appear  before  the  normally  expected  time.  '  In  some 
cases,  Curschman  says,  menstruation  is  normal  in  amount,  in  others  it  is 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     295 

unusually  abundant  and  protracted.  If  the  onset  of  the  fever  precedes  a 
menstrual  period  by  two  or  three  weeks,  the  flow  does  not  as  a  rule  appear 
at  all.  In  the  majority  of  cases,  Curschman  has  found  that  amenorrhea  is 
present  throughout  the  course  of  the  disease  and  during  the  first  part  of 
the  convalescence.  This  is  especially  true  of  severe  and  protracted  cases 
of  typhoid,  the  proportion  of  these  in  which  amenorrhea  is  noted  being 
placed  at  60  per  cent.  When  menstruation  continues  during  typhoid,  it 
is  usually  scanty  in  amount.  Occasionally,  though  rarely,  rather  profuse 
uterine  hemorrhage  may  occur  at  irregular  intervals,  even  during  the 
febrile   stage  of  the  disease. 

After  severe  and  protracted  attacks  of  typhoid  menstruation  is  likely  to 
be  absent  even  after  defervesence,  perhaps  for  a  period  of  two  or  three 
months.  When  the  disease,  on  the  other  hand,  has  been  mild,  menstrua- 
tion usually  recurs  very  early  in  the  convalescence. 

Curschman  lays  stress  upon  the  evil  portent  of  profuse  uterine  hemor- 
rhage occurring  at  the  height  of  typhoid.  This  may  occur  in  the  so-called 
hemorrhagic  type  of  the  disease,  the  hemorrhage  being  .analogous  to  that 
which  is  sometimes  seen  in  the  grave  forms  of  smallpox.  Barthel  also, 
from  the  study  of  a  large  series  of  cases  as  far  back  as  1882,  arrived  at 
conclusions  somewhat  similar  to  those  already  discussed.  He  stated  these 
as  follows:  (i)  uterine  hemorrhage,  the  so-called  "  pseudomenstrua- 
tion,"  is  not  by  any  means  common  in  typhoid;  (2)  when  the  menstrual 
period  occurs  within  the  first  five  days  after  the  onset  of  the  disease,  the 
flow  almost  always  appears  at  the  regular  time;  (3)  when  the  menstrual 
period  is  expected  after  the  fourteenth  day  of  the  disease,  the  flow  does  not 
appear;  (4)  when  the  date  of  the  period  falls  between  the  sixth  and  four- 
teenth days  of  the  illness,  the  flow  may  or  may  not  appear. 

Toward  the  end  of  the  disease,  or  during  the  period  of  convalescence, 
peri-uterine  hematocele  may  occur,  as  was  pointed  out  by  Trousseau. 
Much  more  rare  is  hematometra,  a  case  of  which  was  reported  by  Martin. 

Menstruation  During  Convalescence. —  When  menstruation  re- 
turns after  an  attack  of  typhoid,  it  is  as  a  rule  either  normal  or  subnormal 
in  amount.  Occasionally,  however,  the  flow  is  very  profuse,  so  that  the 
patient  may  be  considerably  weakened  and  her  convalescence  retarded. 
Sometimes,  also,  women  who  have  menstruated  without  pain  before  an 
attack  of  typhoid  may  complain  of  considerable  discomfort  afterward. 

Effect  of  Menstruation  Upon  Typhoid  Fever. — General  Consider- 
ations.—  Although  writers  on  internal  medicine,  even  the  authors  of  the 
large  systems,  make  surprisingly  little  mention  of  the  influence  of  menstru- 
ation on  the  course  of  typhoid  fever,  there  can  be  little  doubt  that  this  in- 
fluence may  at  times  be  of  considerable  importance.  This  is  well  empha- 
sized by  Stengel,  whose  paper  is  the  only  exhaustive  one  on  this  subject 
which  I  have  been  able  to  find. 

Importance  of  Relation  of  Menstrual  Date  to  Time  of  Onset  of 


296  MENSTRUATION  AND  ITS  DISORDERS 

Disease. —  Stengel  states  that  when  the  onset  of  typhoid  coincides  with  a 
menstrual  period,  it  is  apt  to  be  very  severe.  This  applies  especially  to 
young  girls  who  have  only  recently  acquired  the  menstrual  function.  The 
disease  is  perhaps  most  violent  in  its  onset  when  the  menses  fail  to  appear, 
although  it  may  be  severe  even  when  menstruation  occurs.  In  either 
event,  the  onset  of  typhoid  is  apt  to  be  more  abrupt  when  it  occurs  at  the 
time  of  menstruation,  the  temperature  often  reaching  its  maximum  almost 
immediately,  and  remaining  very  high  for  several  days..  Nervous  symp- 
toms may  be  prominent  in  such  cases. 

Coldness,  shivering,  extreme  sensitiveness  to  cold  and  hydrotherapeutic 
measures,  pain  in  the  lower  part  of  the  abdomen,  and  sometimes  hysterical 
manifestations  are  among  the  symptoms  which  Stengel  observed  in  these 
cases.  Attempts  to  control  the  fever  by  the  usual  cold  sponging  or  cold 
packs  often  increase  the  patient's  discomfort.  It  can  easily  be  understood 
that  a  diagnosis  of  perforation  may  be  made  on  account  of  the  sharp  pain 
often  associated  with  menstruation,  especially  when  with  it  are  observed 
the  other  symptoms  above  noted.  I  have  personally  seen  one  case  in  which 
operation  was  done  in  such  a  case. 

Effect  of  Menstruation  on  Fever. —  Not  only  may  menstruation 
intensify  the  severity  of  the  onset  of  typhoid,  but  it  may  also  cause  a  more 
or  less  marked  recurrence  of  the  fever  at  the  time  the  next  menstrual 
period  is  due,  whether  the  flow  appears  or  not.  This  is  shown  in  several 
cases  reported  by  Stengel.  The  most  striking  of  these  was  that  of  a  lady 
of  forty-six  years,  who  was  taken  sick  on  May  i.  After  a  preliminary 
attack  of  marked  severity  convalescence  began  in  the  early  part  of  June, 
but  it  was  interrupted  in  the  middle  of  that  month,  as  well  as  in  July  and 
August,  by  a  recurrence  of  fever. 

Each  recurrence  lasted  about  one  week  and  was  attended  with  remarka- 
bly  severe  nervous  symptoms,  but  without  any  of  the  ordinary  indications 
of  an  actual  relapse.  These  recurrences  were  accurately  timed  to  the  men- 
strual periods,  although  there  was  no  evidence  of  menstrual  flow.  After 
her  recovery  from  typhoid,  this  patient  never  again  menstruated,  and  never 
exhibited  any  of  the  usual  symptoms  of  the  menopause.  Before  the  attack 
her  menstruation  had  been  very  regular. 

Influence  of  Menstruation  on  Treatment  of  Typhoid. —  As  for 
the  management  of  typhoid  when  its  onset  coincides  with  menstruation  and 
when  the  fever  is  high,  Stengel  believes  that  the  usual  cold  water  treatment 
can  be  only  partially  successful.  When  sponging  or  bathing  has  been  used, 
he  has  observed  no  influence  on  the  temperature,  and,  as  a  matter  of  fact, 
the  nervous  shock  attending  such  measures  may  cause  an  actual  increase  of 
the  fever.  He  believes,  therefore,  that  the  employment  of  cold  in  such 
cases  should  always  be  carefully  considered,  and  that  it  must  often  be 
modified  or  given  up  altogether. 

In  some  cases  warm  sponging  or  even  bathing  in  water  of  much  higher 
temperature  than  that  ordinarily  used  is  advised.     Stengel  considers   it 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     297 

bad  practice  to  tub  patients  during  the  menstrual  period.  If  hyperpyrexia 
be  present,  he  has  often  obtained  good  results  from  the  use  of  sedatives, 
together  with  the  modified  hydrotherapy  above  described.  In  the  more 
severe  cases,  a  hypodermic  of  morphine  (about  i/6  grain)  may  have  an 
immediate  and  lasting  effect  on  the  temperature,  while  in  the  milder  cases, 
small  doses  of  codein  may  suffice,  especially  if  given  a  short  time  before  the 
bath  or  sponge. 

PNEUMONIA  AND  MENSTRUATION 

Effect  of  Pneumonia  on  Menstruation. —  According  to  Rosenstrauss, 
there  is  a  tendency  to  excessive  menstruation  in  pneumonia,  especially 
when  the  onset  of  the  disease  coincides  with  a  menstrual  period.  More- 
over, the  flow  is  apt  to  be  brought  on  prematurely  by  the  onset  of  the  pneu- 
monia. Massin,  from  the  examination  of  the  uterus  removed  at  autopsy 
from  a  twenty-three  year  old  woman  who  had  died  of  pneumonia,  believes 
that  this  disease,  as  well  as  typhoid  and  other  infectious  processes,  causes 
marked  pathological  changes  in,  and  perhaps  total  loss  of,  the  uterine  epithe- 
lium, together  with  a  congestion  of  the  uterine  blood  vessels.  His  find- 
ings have  not  been  substantiated. 

Occurrence  of  Menstruation. —  The  course  of  lobar  pneumonia  is 
usually  quite  short,  and,  when  the  disease  falls  between  menstrual  periods, 
the  latter  may  not  be  materially  affected,  especially  if  the  attack  be  mild. 
Griesinger  (Osier  and  McCrae)  has  reported  on  the  occurrence  of  men- 
struation during  pneumonia.  In  one  case  normal  menstruation  occurred 
on  the  third  day  of  an  attack  of  pneumonia.  In  another  case  menstruation 
occurred  on  the  fourth  day  of  an  attack,  ten  days  before  it  was  due.  Be- 
ginning with  the  onset  of  the  flow  there  were  evening  remissions  of  the 
temperature,  followed  by  a  slow  defervescence. 

OTHER  INFECTIOUS  DISEASES  AND  MENSTRUATION 

Syphilis. —  Syphilis  appears  often  to  be  without  striking  effect  on 
menstruation  in  the  primary  and  secondary  stages  of  the  disease.  Menor- 
rhagia has,  however,  been  reported  as  a  symptom  of  syphilitic  disease. 
Rosenstrauss,  for  example,  records  13  cases  of  menorrhagia  treated  at  the 
Charite  Clinic  in  Berlin,  in  all  of  which  the  Wassermann  reaction  was 
positive  and  in  all  of  whom  no  demonstrable  pelvic  lesion  was  found. 
Curettage  yielded  a  normal  endometrium  in  all  the  cases.  Similar  cases 
have  been  reported  by  others. 

Meirowsky  and  Frankenstein  have,  on  the  other  hand,  called  attention 
to  the  possibility  that  amenorrhea  may  be  a  symptom  of  tertiary  lues. 
They  report  three  cases,  in  which  the  amenorrhea  had  lasted  from  six  to 
eight  years.  The  patients  were  from  twenty-eight  to  forty-six  years  of_ 
age.     All  were  suffering  with  severe  manifestations  of  tertiary  syphilis 


29B  MENSTRUATION  AND  ITS  DISORDERS 

and,  under  the  mercury  and  iodid  given  for  this,  menstruation  was  restored. 
In  the  younger  women  it  was  quite  normal,  but  in  the  woman  of  forty-six 
it  assumed  a  vicarious  character,  epistaxis  recurring  regularly  at  the  men- 
strual periods.  The  authors  emphasize  the  importance  of  specific  treat- 
ment in  amenorrhea  in  women  whose  history  suggests  the  possibility  of 
syphilis.  In  tbeir  opinion,  the  direct  cause  of  the  amenorrhea  in  these 
cases  is  a  syphilitic  involvement  of  the  ovaries. 

Influenza. —  In  this  disease  menstruation,  according  to  Finkler,  is 
often  rather  excessive.  Haken  has  observed  violent  metrorrhagia  in 
certain  cases  and  Helling  reports  uterine  hemorrhage  during  the  course  of 
influenza  in  a  woman  of  forty-nine  who  had  not  menstruated  for  five  years. 
The  tendency  of  influenza  to  cause  excessive  menstruation  with  not  infre- 
quently an  "  anticipation  "  of  the  period,  was  a  rather  general  observation 
during  the  recent  great  epidemic  of  the  disease.  This  is  well  shown  in 
the  recent  report  of  Esch. 

Acute  Exanthematous  Diseases. —  Observations  on  this  subject  are 
apparently  quite  rare,  most  of  the  patients  with  these  diseases  being  below 
the  age  of  puberty.  When  older  individuals  are  affected,  it  would  seem 
that  the  influence  of  such  diseases  on  menstruation  is  similar  to  that  of 
pneumonia  and  other  acute  infections.  A  rather  interesting  case  of  "  men- 
struation during  measles,"  in  a  girl  of  nine,  has  been  reported  by  Gemmell. 
The  day  following  the  appearance  of  the  characteristic  eruption  a  dis- 
charge of  blood  appeared  from  the  vagina,  which  Gemmell  assumes  to 
have  been  menstrual  in  character.  This  supposition,  however,  seems  to 
me  to  be  unjustifiable,  especially  since,  as  he  says,  inquiries  showed  that 
there  was  no  renewal  of  the  vaginal  discharge  after  the  subsidence  of  the 
measles  rash. 

Other  Infectious  Diseases. —  Cholera  and  smallpox,  according  to 
Rosenstrauss  and  Massin,  exert  practically  the  same  effect  on  menstruation 
as  do  typhoid,  pneumonia  and  other  acute  infectious  diseases.  In  leprosy, 
according  to  Morrow,  menstruation  is,  especially  in  long  standing  cases, 
irregular  and  may  cease  altogether.  When  leprosy  appears  before  the  age 
of  puberty,  menstruation  rarely  appears,  the  disease  appearing  to  exert  an 
inhibitory  influence  on  the  menstrual  process. 

DISEASES  OF  THE  BLOOD  IN  RELATION  TO 
MENSTRUATION 

Chlorosis. —  Characteristics  of  the  Disease. —  As  Friedrich  Miiller 
puts  it,  chlorosis  is  a  "  prerogative  of  the  female  sex."  It  has  often  been 
remarked  that  the  frequency  of  this  malady  is  on  the  wane  in  this  country, 
and  this  would  seem  to  be  substantiated  by  the  statistics  of  Cabot.  The 
disease  derives  its  name  from  the  greenish  hue  of  many  of  its  victims, 
although  it  must  be  emphasized  that  this  is  not  by  any  means  constant. 
The  characteristic  blood  changes  consist  in  a  deficiency  of  hemoglobin  in 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     299 

the  red  corpuscles  and,  to  a  less  extent,  in  an  actual  decrease  in  the  number 
of  corpuscles.     The  plasma,  according  to  Allbutt,  is  relatively  increased. 

Chlorosis  is  characteristically  a  disease  of  puberty,  the  usual  age  of  the 
primary  attack  being  from  14  to  21  years.  It  is  said  to  be  especially  severe 
if  it  appears  before  the  onset  of  menstruation.  A  first  attack  is  rare  after 
the  age  of  24.  Stockman  gives  2-}^  as  the  highest  age  in  a  series  of  63 
cases.     Forty-one  were  between  the  ages  of  15  and  20  years. 

Although  the  common  association  of  amenorrhea  with  chlorosis  has  long 
been  known,  it  was  Virchow  who  first  called  attention  to  the  fact  that  the 
menstrual  disturbance  may  have  an  organic  basis.  He  asserted  that,  to- 
gether with  certain  other  characteristic  changes,  a  hypoplasia  of  the  repro- 
ductive organs  is  an  invariable  finding  in  chlorosis.  In  addition  he  de- 
scribed an  arrest  of  development  in  the  entire  arterial  system,  the  aorta 
scarcely  admitting  the  tip  of  the  finger  and  the  abdominal  aorta  being  no 
bigger  than  the  ordinary  size  of  the  iliac  or  femoral  arteries. 

Effect  of  Chlorosis  on  AIenstruation. —  In  the  majority  of  cases  the 
symptoms  of  chlorosis  do'  not  appear  at  puberty,  but  some  years  later. 
Von  Noorden's  analysis  of  215  cases  showed  that  56  (26  per  cent)  had 
never  menstruated,  while  in  129  (60  per  cent)  there  was  a  considerable  in- 
terval between  puberty  and  the  beginning  of  the  disease.  According  to 
Stephenson,  a  chlorotic  diathesis  tends  to  accelerate  the  age  of  menstrual 
onset.  The  same  author  finds  also  that  before  the  actual  onset  of  the  chlo- 
rosis menstruation  was  normal  in  47.5  per  cent  of  cases;  that  in  20.7  per 
cent  there  was  a  slight  deficiency;  in  26.7  per  cent  it  was  markedly  defi- 
cient; in  2.y  per  cent  it  was  imperfectly  established;  and  in  2.1  per  cent 
there  was  primary  amenorrhea.  He  concludes,  therefore,  that  "  in  fully 
one-half  of  the  cases,  the  chlorotic  characters,  that  of  scantiness  in  amount 
of  the  discharge  and  increase  in  the  interval  between  the  periods,  were 
stamped  upon  the  menstrual  function  before  the  development  of  active 
chlorosis." 

Amenorrhea  the  Common  Menstrual  Symptom  in  Chlorosis. — In 
by  far  the  largest  number  of  cases  of  chlorosis,  menstruation  is  deficient 
or  absent  altogether.  In  a  much  smaller  group,  there  may  be  exces- 
sive menstruation.  According  to  Cabot,  the  menses  were  absent  in  120 
cases  of  a  series  of  387,  they  were  irregular  in  81,  increased  in  57,  and  un- 
usually painful  in  47.  In  Stockman's  63  cases,  menstruation  was  scanty 
or  irregular  in  29,  absent  in  12,  normal  in  4,  profuse  in  10.  In  3  menstru- 
ation had  never  appeared,  and  in  5  there  was  no  note  concerning  this. 

Stephenson's  figures,  on  the  other  hand,  show  that  of  177  cases  there  was 
not  one  with  profuse  menstruation  either  before  or  after  the  development  of 
the  disease.  In  one  case  only  the  discharge  was  described  as  rather  free, 
and  in  3  as  too  frequent,  but  scanty.  In  2  cases  menstruation  remained 
normal.  In  all  the  remaining  171  cases,  or  96.6  per  cent,  there  was  more 
or  less  marked  deficiency  of  the  menstrual  flow.  In  58.7  per  cent  it  was 
scanty,  irregular,  and  often  painful,  while  in  37.8  per  cent  there  was  com- 


300  MENSTRUATION  AND  ITS  DISORDERS 

plete  amenorrhea  for  periods  varying  from  two  months  to  two  years.  From 
these  various  reports,  therefore,  it  is  evident  that  the  usual  effect  of  chlo- 
rosis is  to  bring  about  a  diminution  in  the  menstrual  flow. 

Menorrhagia  Occasionally  Observed. —  When  menorrhagia  occurs, 
it  may  in  certain  cases  assume  very  serious  proportions.  Doran  reports  a 
fatal  case  in  a  very  anemic  girl,  aged  i6,  who  had  suffered  with  chlorosis 
for  more  than  a  year.  The  flow  was  scanty  until  shortly  before  death, 
when  profuse  metrorrhagia  set  in,  resisting  all  treatment,  including  trans- 
fusion, and  leading  to  a  fatal  issue.  A  somewhat  similar  case  is  reported 
by  Clapham,  whose  patient  was  a  girl  of  i8  with  well  marked  chlorosis.  The 
hemorrhage  was  so  profuse  that  it  caused  syncope,  vomiting,  dilated  pu- 
pils, and  jactitation,  the  girl's  condition  becoming  apparently  moribund. 
The  patient  finally  recovered  from  this  attack,  the  subsequent  periods  being 
attended  with  less  bleeding.  Still  another  case  of  this  type  is  recorded  by 
Kromer. 

Dysmenorrhea  a  Frequent  Symptom. —  Dysmenorrhea  is  a  frequent 
symptom  of  chlorosis,  as  may  be  noted  from  the  statistics  of  Cabot,  quoted 
above.  This  is  not  surprising  when  one  considers  the  fact  that  the  uterus  is 
so  frequently  underdeveloped  in  these  cases,  and,  secondly,  that  the  de- 
praved vitality  of  the  patient  increases  her  susceptibility  to  pain  to  such  an 
extent  that  a  normal  menstrual  discomfort  is  magnified  into  actual  pain. 

Treatment  of  Menstrual  Disorders  of  Chlorosis. —  The  treatment 
of  the  various  menstrual  disorders  associated  with  chlorosis  is  fundamen- 
tally the  treatment  of  the  chlorosis  itself.  This  has  been  sketched  in  Chap- 
ter XVIII.      (See  also  Chapters  XX  and  XXII.) 

Effect  of  Menstruation  on  Chlorosis. —  The  characteristic  deficiency 
of  menstruation  in  chlorosis  is  commonly  looked  upon  as  a  protec- 
tive phenomenon,  i.  e.,  as  an  effort  on  the  part  of  nature  to  conserve  the 
patient's  blood  and  strength.  This  idea  would  seem  to  be  borne  out  by 
the  observation  of  Sir  William  Gowers,  who  noted  a  fall  of  from  lo  to  20 
per  cent  in  the  number  of  red  blood  corpuscles  after  a  menstrual  period. 
Allbutt  thinks  that  the  cases  in  which  there  is  a  low  count  of  red  blood  cor- 
puscles, of  perhaps  3,000,000  or  less  to  the  cubic  millim'Ctre,  are  those  in 
which  amenorrhea  is  not  present,  i.  e.,  those  in  which  menstruation  is 
either  normal  or  excessive. 

Harmfulness  of  Emmenagogues. — ^The  above  facts  emphasize  not 
only  the  fallacy  but  also  the  actual  harmfulness  of  the  efforts  which  even 
physicians  sometimes  make  to  "  bring  on  the  flow  "  in  cases  of  amenor- 
rhea. Allbutt  quotes  an  old  medical  friend  as  being  in  the  habit  of  giving 
to  mothers  who  brought  their  daughters  for  this  purpose  the  following  apt 
suggestion :     "  Madam,  when  the  works  are  put  in  order  the  clock  will 

strike." 

Pernicious  Anemia. —  According  to  Rosenstrauss,  the  effect  of  per- 
nicious anemia  upon  menstruation  is  altogether  similar  to  that  of  chlorosis. 

Leukemia. — Virchow  long  since  pointed  out  that  menstrual  disorders 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     301 

are  very  frequently  associated  with  leukemia.  Menorrhagia,  sometimes 
associated  with  intermenstrual  bleeding,  is  much  more  common  than 
deficient  menstruation.  Virchow  considers  that  a  relation  with  the  func- 
tions of  the  genital  apparatus  is  a  constant  feature  of  leukemia.  Mosler 
also  asserts  that  there  is  a  connection  between  uterine  hemorrhage  and  the 
function  of  the  spleen,  the  latter  organ  after  such  hemorrhage  often  showing 
acute  enlargement,  while  the  white  corpuscles  of  the  blood  are  somewhat 
increased  in  number. 

Of  21  cases  of  leukem'ia,  Mosler  stated  that  in  fully  i6  there  was  some 
form  of  menstrual  anomaly.  In  many  women  the  menses  were  absent. 
Contrary  to  the  findings  of  Virchow,  Mosler  found  profuse  menstruation 
in  only  two  of  his  cases.  In  one  patient  the  menses  had  not  yet  appeared. 
Nobl  reported  a  case  of  acute  leukemia  occurring  in  a  woman  of  30,  in 
whom  the  malady  appeared  to  begin  with  hemorrhage  in  the  skin  and 
mucous  membranes.  No  pathological  lesions  in  the  generative  tract  were 
demonstrable.  A  somewhat  similar  case  in  a  woman  of  40  was  reported 
by  Hindenberg.  In  this  case  profuse  bleeding  took  place  from  the  nose  and 
gums,  but  none  from  the  genital  tract. 

Hemophilia. —  In  the  numerous  articles  on  this  interesting  disease, 
very  little  is  said  as  to  the  effect  on  menstruation.  Osier  states :  "In  girls, 
menstruation  is  sometimes  early  and  excessive,  but  happily  in  the  female 
members  of  hemophilic  families  neither  this  function  nor  the  act  of  parturi- 
tion bring  with  them  special  dangers  ".  Cases  of  severe  menstrual  bleeding 
in  hemophilia  have,  however,  been  reported  by  Townsend  and  others. 

DISEASES  OF  THE  THYROID  GLAND  IN  RELATION  TO 

MENSTRUATION 

Graves'  Disease  and  Menstruation. —  There  is  considerable  discrep- 
ancy between  various  authors  as  to  the  effect  of  hyperthyroidism  upon 
menstruation.  According  to  some,  menstruation  is  deficient  in  such  cases, 
while  others  state  that  it  is  apt  to  be  excessive.  These  differences  of 
opinion  are  not  due  to  faulty  observation,  but  are  almost  surely  to  be 
explained  by  the  fact  that  individual  differences  really  do  exist. 

The  two  factors  which  suggest  themselves  as  possibly  responsible  for 
these  differences  are  (i)  the  stage  of  the  disease  under  study;  and  (2)  the 
type  of  the  disease.  Surgeons  are  familiar  with  the  fact  that  the  individual 
with  Basedow's  disease  may  exhibit  marked  fluctuations  in  the  secretory 
activity  of  the  thyroid  gland  at  different  times.  They  are  also  becoming 
more  and  more  aware  of  the  fact  that  the  clinical  picture  of  Basedow's 
disease  may  be  partly  due  to  abnormal  activity  of  other  ductless  glands,  in 
association  with  the  thyroid.  The  thymus  is  of  especial  importance  in  this 
■  regard,  as  recent  work  has  shown. 

According  to  Allbutt,  menstruation  in  Graves'  disease  is  usually  irregu- 
lar.    Amenorrhea  is  present  in  some  cases,   and  menorrhagia  in  others. 


302  MENSTRUATION  AND  ITS  DISORDERS 

Russell  Reynolds,  again,  found  menstruation  to  be  normal  in  46  of  49  cases 
of  exophthalmic  goiter. 

Bloch  found  that  menstruation  was  absent  in  3  of  a  series  of  12  cases  of 
Basedow's  disease  which  she  studied.  She  quotes  Schott  as  stating  that 
the  occurrence  of  menstruation  exercises  a  harmful  influence  on  the  course 
of  the  disease,  but  believes  that  he  is  in  error  in  this  belief. 

Some  authors,  as  Kleinw^achter  and  Hademaker,  state  that  in  extreme 
cases  of  Graves'  disease  there  is  an  atrophy  of  the  entire  genital  tract,  with 
complete  amenorrhea.  Others  believe  that  the  amenorrhea  so  often  noted 
is  due  to  a  toxic  effect  exerted  on  the  ovary. 

Myxedema  and  Menstruation. —  The  same  differences  in  the  effect 
on  menstruation  which  are  observed  with  Graves'  disease  are  noted  also  in 
myxedema.  Menstruation  may  be  absent  or  scanty,  it  may  be  normal,  or 
it  may  be  excessive.  Bromwell  reports  a  case  in  which  it  was  perfectly 
regular  in  a  woman  of  36  who  had  had  myxedema  since  the  age  of  25.  In 
a  case  reported  by  Murray,  on  the  other  hand,  menstruation  had  occurred 
only  once  in  the  preceding  six  years.  After  treatment  with  thyroid  extract 
menstruation  returned  for  several  periods,  even  though  the  woman  was 
over  46  years  of  age. 

Menorrhagia  is  also  sometimes  observed  and  may  be  marked.  In  a  case 
reported  by  Dock  it  seemed  to  be  the  first  symptom  of  the  disorder,  being 
soon  followed  by  a  yellowish  hue  to  the  skin,  this  being  at  first  ascribed  to 
the  loss  of  blood. 

The  relation  of  the  thyroid  to  the  menstrual  process  is  further  discussed 
in  Chapter  XXIV. 

DIABETES  AND  MENSTRUATION 

In  many  cases  of  diabetes,  especially  those  of  milder  grades  of  severity, 
menstruation  may  occur  quite  normally.  Even  in  the  severe  forms  of  the 
disease,  the  patient  may  menstruate  regularly  until  the  terminal  stages  ""of 
the  disease.  In  a  certain  number  of  cases,  however,  amenorrhea  is  a 
symptom.  Israel  and  Hofmeier  look  upon  it  as  a  frequent  concomitant. 
Lenhartz  also  has  found  it  common,  and  attributes  it  to  atrophy  of  the 
generative  organs.  Naunyn,  who  has  had  such  a  tremendous  experience 
with  diabetes,  states  that  amenorrhea  occurs  only  in  the  late  stages  of  the 
disease.  It  is  therefore  looked  upon  as  due  to  the  general  debility  associated 
with  the  disease. 

As  to  the  influence  of  menstruation  upon  the.  course  of  diabetes,  the 
general  impression  among  those  who  have  studied  this  question  seems  to  be 
that  this  is  unfavorable.  Naunyn  is  of  this  opinion,  and  believes  that  this 
fact  has  received  too  little  attention  from  clinicians.  Lecorche  also  holds 
this  opinion.  From  a  systematic  study  of  the  sugar  output  in  a  small  series 
of  cases,  Rosenstrauss  found  that  the  occurrence  of  menstruation  is  often 
accompanied  by  a  rise  in  the  sugar  output  and  occasionally  by  the  appear- 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     303 

ance  of  acetone  in  the  urine.     This  ohservation  is  apparently  borne  out  by 
a  recent  report  of  Harrop  and  Mosenthal. 

GASTRO-INTESTINAL  DISEASES  AND   MENSTRUATION 

Effect  of  Menstruation  on  Secretory  and  Motor  Functions  of  the. 
Stomach. —  In  the  investigation  of  a  number  of  patients  during  men- 
struation, Wolfe  found  an  increase  both  in  the  free  hydrochloric  acid  and 
in  the  total  acidity  of  the  stomach  contents.  Moreover,  the  amount  of 
gastric  juice  secreted  was  greater  than  normal.  This  he  attributed  to 
reflex  nervous  stimulation.  The  motor  activity  was  found  to  be  notably 
diminished.  If  hypersecretion  be  present  before  menstruation,  it  may  be- 
come an  actual  gastrorrhea  during  the  period.  He  calls  attention  to  the 
fact  that  gastric  analyses  made  during  menstruation  may  give  misleading 
results,  and  he  urges  that  female  patients  with  gastric  ulcer  should  observe 
an  especially  strict  regime  at  the  time  of  menstruation,  on  account  of  the 
greater  danger  of  hemorrhage  at  that  time. 

Kehrer's  results  are  not  quite  so  definite.  He  finds  that  the  hydrochloric 
acid  content  is  unchanged  in  normal  menstruation  of  moderate  severity,  and 
that  it  is  decreased  in  severe  hemorrhage,  and  increased  in  nervous  women 
with  scanty  menstruation. 

Stomach  Disorders  and  Menstruation. —  Plonies  observed  an  exacer- 
bation of  symptoms  in  all  but  17  per  cent  of  450  female  patients  with  various 
stomach  affections.  He  thinks  that  both  the  sympathetic  and  the  vagus 
nerve  systems  become  hyperexcitable  during  this  period,  and  that  the  in- 
creased vulnerability  of  the  intestinal  tract  during  the  menstrual  period 
imposes  the  necessity  for  strict  regulation  of  the  diet,  especially  to  ward  off 
relapses.  Menorrhagia  without  other  discoverable  cause,  he  believes,  is 
sometimes  traceable  to  the  influence  of  the  toxins  from  a  stomach  disorder, 
plus  the  effect  of  the  anemia  and  insufficient  nourishment  so  often  found 
with  gastric  disease. 

Liver  Diseases. —  Menstrual  Hyperemia  of  the  Liver  and  Men- 
strual Jaundice  (Icterus  Menstrualis). —  In  1872  Senator  described 
four  cases  of  recurring  icterus  appearing  immediately  before  or  during 
menstruation.  As  soon  as  the  menstrual  flow  became  well  established,  the 
icterus  disappeared.  In  several  of  the  attacks,  the  liver  was  found  to  be 
swollen,  the  feces  decolorized,  and  the  gastric  functions  disturbed.  In  the 
intermenstrual  intervals  the  general  health  was  unimpaired. 

Senator  assumed  that  in  these  cases  the  hyperemic  condition  of  the  liver 
often  observed  during  menstruation  was  complicated  by  swelling  of  the 
mucosa  of  the  bile  passages.  According  to  Senator,  mild  degrees  of  jaun- 
dice are  often  seen  during  menstruation.  He  quotes  Frerichs  as  having 
described  under  the  heading  of  "  neuralgia  of  the  liver  "  a  case  in  which 
for  several  years  there  were  attacks  of  icterus  accompanied  by  pain  and 
swelling  of  the  liver  immediately  preceding  menstruation. 


304  MENSTRUATION  AND  ITS  DISORDERS 

Chvostek,  in  a  study  of  30  women  from  this  standpoint,  found  that  all 
but  3  of  the  series  showed  an  increase  in  the  size  of  the  liver  during  the 
menstrual  periods,  the  lower  margin  being  one  or  two  finger  breadths  lower 
than  normally.  There  was  nothing  to  indicate  any  pathologic  condition 
in  the  liver,  kidneys  or  circulatory  organs.  He  suggests  that  this  menstrual 
hyperemia  of  the  liver  may  be  due  to  the  direct  effect  of  the  internal  secre- 
tion of  the  ovary. 

Cholelithiasis. —  The  occurrence  of  a  menstrual  hyperemia  of  the.: 
liver  no  doubt  explains  the  exacerbations  sometimes  noted  in  hepatic  and; 
gall  bladder  disease  at  the  menstrual  epochs.  Metzger,  for  example,  re- 
ported a  case  of  cholelithiasis  in  which  icterus  occurred  regularly  with  each 
menstrual  period.  Operation  revealed  a  gall  stone  which  apparently  could 
cause  obstruction  of  the  bile  flow  only  during  the  hyperemia  of  the  men-; 
struation.  ';c 

Binet,  after  examining  137  women  with  undoubted  cholelithiasis,  found? 
on  reviewing  their  histories  that  these  patients  suffered  from  attacks  of  indi-^ 
gestion  and  abdominal  pain  before  each  menstrual  period.  He  states  that^] 
whenever  in  a  woman  gastric  pains  appear  before  the  menstrual  perio'ds, 
biliary  lithiasis  should  be  suspected.  Out  of  100  women,  63  had  been  seen^ 
in  an  undoubted  menstrual  crisis  or  bihary  colic.  Of  the  37  others,  11  had, 
such  a  crisis  after  observation  had  been  begun,  and  26  others  showed  paiii-- 
less  menstruation  after  they  had  been  subjected  to  rigorous  antilithiasis 
treatment. 

JOINT  DISEASES  AND  MENSTRUATION 

Acute  Articular  Rheumatism  and  "  Menstrual  Arthritis." —  It  was 

Riebold  who  first  called  attention  to  what  he  called  "  acute  menstrual  articu- 
lar rheumatism."  The  course  of  this  affection,  he  says,  is  similar  to  that 
of  the  classic  type,  except  perhaps  for  its  unusual  mildness  in  some  cases. 
In  eight  of  the  fifteen  cases  which  he  records,  only  the  joints  of  the  feet 
were  swollen  and  painful,  and  the  fever  was  slight  and  transient.  The 
heart  was  not  perfectly  normal  in  any  of  these  15  cases.  A  valvular  defect 
was  found  in  all,  and  was  quite  serious  in  some.  The  changes  in  the 
heart  were  thus  out  of  all  proportion  to  the  severity  of  the  joint  lesions. 

The  explanation  of  this  "menstrual  arthritis,"  Riebold  believes,  is  to 
be  found  in  the  fact  that  the  menstruating  uterus  may  occasionally  be  the 
source  of  infections.  He  says  that  fever  accompanying  menstruation  is  by 
no  means  uncommon,  and  is  the  result  of  the  absorption  of  bacterial  toxins 
or  products  of  decomposition  through  the  menstruating  uterus.  This 
absorptive  action,  he  believes,  is  also  evidenced  by  the  occasional  occurrence, 
with  menstruation,  of  such  affections  as  urticaria,  erythema,  herpes  and, 
neuralgia.  f  n  ,ii ,  ..  ' 

In  a  similar  way,  he  believes  that  infection  or  intoxication  from  thcmefi^ 
struating  uterus  may  give  rise  to  actual  polyarthritis,  ^.rlij^^one^c^s^  at  •|eaS/t;, 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     3C5 

staphylococci  were  found  in  the  blood  stream,  the  only  possible  source,  in 
Riebold's  opinion,  being  the  menstruating  uterus. 

A  series  of  four  cases  of  "  menstrual  arthritis  "  of  the  type  described  by 
Riebold  have  been  reported  by  Morgan.  One  of  these  is  of  especial  interest. 
It  was  that  of  a  girl  who'  at  the  age  of  twelve  years  and  five  months  was 
taken  with  headache,  fever,  pain,  and  swelling  in  the  joints  of  the  knees, 
wrists,  and  shoulders  successively.  The  case  was  diagnosed  as  rheumatism 
and  appropriate  treatment  instituted,  no  thought  being  given  to  the  men- 
strual function,  which  had  not  yet  appeared.  The  next  day,  however,  the 
menstrual  flow  appeared,  the  rheumatic  symptoms  at  the  same  time  sub- 
siding. 

What  is  more  significant,  however,  is  the  fact  that  for  five  months  these 
pains  in  the  joints  returned  regularly  at  the  menstrual  periods,  and  were 
best  governed  by  putting  the  patient  to  bed  the  day  before  the  expected 
menses,  and  sometimes  administering  the  salicylates.  The  same  periodic 
exacerbation  of  symptoms  at  menstruation  was  noted  also,  to  a  greater  or 
less  degree,  in  the  other  cases  reported  by  Morgan. 

As  to  the  influence  of  menstruation  upon  the  course  of  an  existing 
articular  rheumatism,  this,  while  not  usually  very  striking,  is  sometimes 
quite  evident,  to  say  the  least.  This  is  shown  in  the  study  made  by  Bloch 
at  the  Basel  clinic.  Of  a  series  of  76  patients  with  acute  articular  rheuma- 
tism, 53  menstruated  while  in  the  hospital;  39  of  these  53  (73.58  per  cent) 
showed  no  increase  of  symptoms  at  the  period,  while  14  (26.41  per  cent) 
showed  menstrual  exacerbations.  In  the  great  majority  of  these  cases 
there  was  a  premenstrual  rise  of  temperature,  although  occasionally  a  post- 
menstrual  type  of  fever  was  observed. 

NERVOUS  AND  MENTAL  DISEASES  AS  RELATED  TO 

MENSTRUATION 

Epilepsy. —  In  a  certain  number  of  cases  there  seems  to  be  a  definite 
relation  between  epilepsy  and  the  menstrual  periods  ("  menstrual  epilepsy  "). 
This  question  has  been  studied  by  Gordon,  Spratling  and  a  number  of  other 
authors.  Gordon  analyzed  23  cases  in  which  the  occurrence  of  the  epileptic 
attacks  coincided  definitely  with  the  menstrual  periods.  In  the  inter- 
menstrual periods  all  these  patients  enjoyed  good  health.  The  epileptic 
seizures  always  made  their  appearance  at  the  onset  of  the  menses  in  5 
cases,  during  the  flow  in  2  cases,  at  the  termination  of  the  period  in  2 
cases,  and  a  day  or  two  before  menstruation  in  14  cases.  He  states  that 
in  all  these,  the  regularity  of  the  attacks  at  the  time  of  the  periods  was  so' 
striking  that  the  patients,  being  able  to  foretell  the  seizures,  could  take  the 
proper  precautions  to  avoid  personal  injury  or  accident. 

He  cites  a  rather  striking  case,  reported  by  Diamant,  of  a  girl  of  six  who 
had  commenced  to  menstruate  when  two  years  old.  At  six  the  menses 
ceased  and  were  replaced  by  epileptic  seizures. 


306  MENSTRUATION  AND  ITS  DISORDERS 

Analyzing-  his  cases  to  determine  the  possible  role  of  menstrual  disorders 
in  exciting  epilepsy,  Gordon  finds  that  only  5  of  his  patients  complained  of 
dysmenorrhea,  and  that  even  in  these  gynecological  treatment  was  followed 
by  no  amelioration  in  the  epilepsy.  He  concludes,  therefore,  that  irregu- 
larity or  abnormality  of  menstruation  has  little  to  do  with  the  occurrence  of 
the  epileptic  seizures. 

Spratling,  in  an  earlier  study  of  the  question,  arrived  at  conclusions 
essentially  similar  to  those  of  Gordon.  He  lays  stress  upon  the  fact  that 
menstruation,  when  associated  with  epilepsy,  acts  as  an  exciting  cause 
merely  because  the  predisposition  to  epilepsy  already  exists  in  the  patient. 
He  states  his  conclusions  as  follows : 

( 1 )  That  we  can,  and  must,  in  many  cases  of  epilepsy  that  appear  from 
the  twelfth  to  the  sixteenth  and  eighteenth  year,  coincident  with  the  estab- 
lishment of  the  menstrual  flow  in  women,  ascribe  to  these  changes  the 
power  of  inducing  well  defined  convulsions  that  may  be  epileptic. 

(2)  That,  except  in  the  most  remote  and  exceptional  instances,  these 
periods  in  normal  individuals  have  no  power  to  induce  epilepsy,  or  even 
epileptoid  phenomena. 

(3)  That,  by  searching  carefully,  we  shall  find  in  most  cases  of  epilepsy 
at  this  period,  either  a  previous  history  of  convulsions,  usually  in  infancy, 
or  a  family  or  personal  history  so  tainted  with  a  tendency  to  the  disease 
that  epilepsy  under  the  stress  of  puberty  is  plainly  invited. 

A  case  reported  by  Maguin  illustrates  in  a  forceful  way  the  remarkable 
association  occasionally  observed  between  menstruation  and  epilepsy.  The 
patient  was  a  single  woman  of  31  years.  Her  first  epileptic  seizure  came 
at  17,  with  her  first  menstrual  period.  At  20  she  became  pregnant.  With 
the  cessation  of  menstruation  came  a  disappearance  of  the  epileptic  attacks. 
On  the  reappearance  of  the  menses,  after  the  birth  of  the  child,  the  attacks 
came  on  with  the  same  regularity  as  before  pregnancy  had  occurred.  The 
seizures  were  typically  epileptic  in  every  way,  there  being  no  evidence 
whatever  for  suspecting  a  hysterical  origin. 

Hysteria. —  The  very  term  hysteria  implies  the  uterine  origin  which 
was  formerly  ascribed  to  the  disease.  While  this  old  supposition  has  of 
course  been  quite  generally  abandoned,  it  is  true  that  menstruation  fre- 
quently brings  on  hysterical  seizures  in  girls  or  women  already  predisposed. 
This  is  a  fact  well  known  to  every  practitioner  of  medicine,  who  will  recall 
with  disgust  the  numerous  occasions  on  which  he  has  been  hurriedly  sum- 
moned to  attend  the  hysterical  girl  in  one  of  her  monthly  attacks  of  "  uncon- 
sciousness "  or  "  convulsions." 

In  many  cases  of  this  type  there  is  associated  with  the  hysterical  attack 
a  greater  or  less  degree  of  spasmodic  dysmenorrhea.  The  uterus  is  not 
infrequently  underdeveloped  and  anteflexed.  This  is  borne  out  by  the 
studies  of  Diepgen  and  Schroder  on  75  hysterical  women.  They  found 
that  menstruation  in  such  women  had  as  a  rule  commenced  unusually  late, 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     307 

that  it  was  often  tardy,  and  usually  scanty.  This  they  construe  as  indicative 
of  a  defective  development  of  the  reproductive  organs. 

Insanity. —  When  menstruation  continues  in  the  insane  woman,  it 
may  be  associated  with  a  greater  or  less  degree  of  exacerbation  of  the  mental 
symptoms.  There  is,  however,  a  surprising  lack  of  accurate  observations 
on  this  score. 

As  to  the  influence  of  mental  disease  upon  menstruation,  practically  all 
authors  are  agreed  as  to  the  frequency  with  which  amenorrhea  is  noted 
among  insane  women.  When  menstruation  does  occur,  it  is  apt  to  be 
scanty  and  irregular.  Occasionally,  metrorrhagia  is  observed  in  such  con- 
ditions as  melancholia  (Allbutt  and  Rolleston).  With  improvement  in  the 
mental  condition  of  the  insane  woman,  there  is  a  corresponding  tendency  to 
a  restoration  of  the  normal  regularity  and  character  of  menstruation. 

In  a  recent  study  of  700  feeble  minded  women  in  an  institution,  Swanberg 
and  Haynes  found  that  425  were  menstruating  normally;  177  had  a  physio- 
logic amenorrhea;  and  108  were  suffering  from  menstrual  disturbances, 
chiefly  irregularity,  amenorrhea,  and  dysmenorrhea. 

Since  they  are  critical  periods  in  the  woman's  life,  puberty  and  the  meno- 
pause are  naturally  of  importance  as  factors  in  the  development  of  mental 
disease,  in  women  with  a  hereditary  predisposition.  Of  the  two  the  meno- 
pause is  by  far  the  more  important,  and  it  frequently  marks  the  beginning 
of  various  forms  of  mental  disorder.  These,  however,  are  discussed  under 
a  separate  heading  (Chapter  XV). 

Chronic  Intoxications. —  Both  morphinism  and  alcoholism  are  fre- 
quently associated  with  a  condition  of  amenorrhea.  In  lead  poisoning,  on 
the  other  hand,  Oliver  states  that  menstruation  is  apt  to  be  increased,  in 
many  cases  occurring  every  two  or  three  weeks.  In  a  few  cases,  however, 
amenorrhea  is  noted. 

THE  MENSTRUAL  DERMATOSES 

Occurrence  of  the  Menstrual  Dermatoses. —  In  a  certain  number  of 
cases  a  definite  association  may  be  observed  between  menstruation  and 
various  skin  eruptions,  or  other  dermatoses.  Among  the  authors  who  first 
called  attention  to  the  occurrence  of  these  menstrual  dermatoses  were  Stiller, 
in  1877,  and  Schramm,  in  1878.  Both  of  these  writers  looked  upon  the 
skin  eruption  as  brought  about  in  some  reflex  manner  by  the  menstrual 
phenomenon,  Pauli  (1880)  and  others  observed  such  eruptions  in 
amenorrhea,  and  considered  them  to  be  a  species  of  vicarious  menstrual 
manifestation. 

In  the  light  of  our  modern  knowledge  of  the  role  of  the  internal  secretions 
in  the  causation  of  menstruation,  it  is  probable  that  the  menstrual  skin 
eruptions  are  in  some  unknown  manner  brought  about  by  the  action  of 
these  internal  secretions,  either  of  the  ovary  or  of  the  other  internal  secretory 
glands.     It  would  be  of  no  value  to  speculate  as  to  the  mechanism  involved. 


308  MENSTRUATION  AND  ITS  DISORDERS, 

That  the  function  of  the  reproductive  organs  may  be  Hnked  up  in  some 
way  with  the  activity  of  the  skin  is  iUustrated  by  the  well  known  pigmenta- 
tion so  characteristic  of  pregnancy,  as  well  as  by  the  growth  of  hair  about 
the  genitals  and  in  the  axillae  at  the  time  of  puberty.  It  is  not  surprising, 
therefore,  that  occasionally  one  encounters  various  skin  conditions  in  asso- 
ciation with  the  menstrual  function.  It  may  be  of  interest  to  discuss  briefly 
the  more  important  menstrual  dermatoses  which  have  been  described. 

Herpes. —  The  most  frequent  skin  disorder  noted  at  the  menstrual 
periods  is  herpes.  The  most  common  seats  of  the  herpetic  eruption  are 
the  external  genitalia,  the  face,  the  thighs,  and  the  buttocks.  As  far  back 
as  1853,  Legendre  had  observed  the  frequency  with  which  genital  herpes  is 
associated  with  the  menses.  Of  877  cases  of  genital  herpes  studied  by 
Bergh,  644  or  73.4  per  cent  were  of  menstrual  origin.  There  are  women 
in  whom  almost  every  menstrual  period  is  accompanied  by  herpes.  On  the 
other  hand,  herpes  vulvaris  is  practically  unknown  among  girls  who  have 
not  begun  to  menstruate. 

The  lesions  of  herpes  genitalis  are  usually  found  on  the  labia  majora,  and 
occasionally,  according  to  Opel,  on  the  cervix  or  on  the  vaginal  wall. 
Sometimes  genital  and  facial  herpes  are  observed  synchronously.  In  ra.re 
cases,  especially  in  prostitutes,  genital  herpes  may  be  so  extensive  as  to 
cause  marked  swelling  of  the  genitalia,  with  perhaps  suppuration  and 
ulceration. 

Janowsky  and  Schwing  report  an  unusual  instance  of  menstrual  herpes  in 
which  the  eruption  involved  the  dorsal  surfaces  of  both  hands.  An  even 
more  remarkable  case  was  that  of  Landesberg,  who  observed  a  herpetic 
eruption  on  the  cornea  in  six  consecutive  menstrual  periods  in  a  girl  of  15. 
The  herpes  in  this  case  was  accompanied  by  violent  ciliary  neuralgia. 

Urticaria. —  The  occurrence  of  urticaria  with  menstruation  was  first 
described  by  Hebra.  Interesting  cases  of  this  type  have  been  reported  by 
Schramm,  Joseph,  Schatz,  and  Pick.  Opel  speaks  of  a  case  of  menstrual 
urticaria  in  which  the  eruption  ceased  to  appear  after  the  correction  of  the 
existing  pelvic  lesions  (anteflexion  and  endocervicitis).  I  have  encoun- 
tered several  cases  of  troublesome  urticaria  in  women  at  the  age  of  the 
menopause. 

Angioneurotic  Edema. —  This  interesting  vasomotor  disturbance  is 
not  very  common,  but  when  it  occurs  it  is  apt  to  be  associated  in  some  way 
with  the  menstrual  phenomenon.  Osier  mentions  six  cases  in  which  such 
an  association  was  noted,  the  attacks  in  these  patients  being  most  likely  to 
occur  at  the  menstrual  periods.  He  states  also  that  at  the  menopause  vaso- 
motor phenomena  of  this  type  are  not  infrequent,  patients  often  complain- 
ing, not  only  of  numbness,  but  also  of  localized  and  transitory  swellings  of 
the  hands,  feet,  or  face. 

Erythema. —  This  may  appear  either  in  a  diffuse  or  circumscribed 
form.  Frequently  there  may  be  scarcely  visible  erythematous  splotches  on 
the  cheeks,  forehead,  thigh  or  other  parts  of  the  body.     According  to  Opel, 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     309 

they  are  sometimes  observed  only  in  association  with  the  first  menstruation, 
while  in  other  cases  more  or  less  extensive  erythema  may  be  noted  at  each 
period. 

A  case  of  erythema  multiforme  occurring  with  each  menstrual  period  was 
reported  by  the  late  Dr.  George  M.  Edebohls,  the  patient  being  a  girl  of 
nineteen.  The  eruption  was  always  seated  upon  the  right  side  of  the  face, 
and  always  ran  the  same  course,  the  erythema  increasing  in  intensity  until 
the  third  day  of  the  flow,  when  vesicles  formed  over  the  surface.  These 
dried  into  thin  crusts  on  the  fourth  day,  the  latter  falling  off  a  few  days 
later.     The  entire  process  repeated  itself  at  the  next  menstruation. 

A  more  severe  form  of  erythema,  which  may  even  simulate  eczema  or 
erysipelas,  has  been  described  by  certain  French  authors  under  the  name  of 
erysipele  catamenial  (Greletty)  or  pseudo-erysipelas  (Godot).  Cases  of 
this  type  have  also  been  reported  by  Wagner  and  Joseph. 

Erysipelas. —  It  is  difficult,  In  view^  of. the  specific  etiology  of  genuine 
erysipelas,  to  conceive  of  its  regular  occurrence  with  each  menstrual  period. 
Cases  of  this  type  have,  however,  been  recorded  by  no  less  an  authority 
than  Virchow,  who  speaks  of  menstrual  erysipelas  occurring  regularly  in 
a  girl  of  1 8  who  had  acquired  the  disease  originally  during  a  menstrual 
period.  Opel  suggests  that  such  cases  may  be  due  to  an  increase  at  the 
menstrual  periods  of  the  virulence  of  bacteria  which  may  be  retained  in  the 
skin  of  such  patients. 

Acne. —  It  is  a  well  known  fact  that  acne  is  frequently  observed  in 
girls  at  or  near  the  age  of  puberty,  and  that  the  skin  condition  frequently 
seems  to  become  worse  at  the  time  of  the  menstrual  periods.  Behrend 
reported  a  case  in  which  each  menstruation  was  preceded  by  the  appearance 
of  a  single  acne  pustule  on  the  nose,  upper  lip  or  chin.  At  other  times  there 
was  no  sign  of  an  eruption  anywhere  on  the  body.  Stiller  speaks  of  a  case 
in  which  acne  pustules,  accompanied  by  much  itching,  appeared  on  the  dorsal 
surfaces  of  both  hands  and  feet  before  each  menstrual  period,  in  a  woman 
of  45.  The  eruption  promptly  disappeared  when  menstruation  ceased. 
Gerber  described  a  case  of  acne  rosacea  of  the  nose,  occurring  with  each 
menstrual  period. 

Ecchymoses. —  Menstrual  ecchymoses  were  first  described  by  Stiller. 
In  his  case  they  occurred  a  few  days  before  each  menstruation  for  a  year 
and  a  half,  the  eruption  consisting  of  irregular  bluish  spots  on  the  chin, 
upper  lip,  or  other  parts  of  the  face.  After  the  period,  these  spots  became 
yellowish  and  disappeared.  Wilhelm  observed  a  case  in  w-hich  for  a  year 
similar  ecchymoses  were  noted  on  the  thighs  and  sometimes  also  on  the 
legs,  in  an  otherwise  normal  w^oman  of  29.  In  addition  to  these  cases  of 
subcutaneous  ecchymosis,  actual  bleeding  from  the  skin  has  been  described 
in  connection  with  menstruation.      (See  Chapter  XXIII.) 

Erythema  Nodosum. —  Cases  of  erythema  nodosum  associated  with 
menstruation  have  been  reported  by  Hobbs  and  by  Opel,  The  latter's 
patient  was  a  woman  of  33,  who  for  half  a  year  had  suffered  with  painful 


310  MENSTRUATION  AND  ITS  DISORDERS 

nodes  on  the  anterior  surfaces  of  each  leg,  and  also  on  the  extensor  surfaces 
of  the  left  arm.  The  nodes  always  appeared  a  few  days  before  menstrua- 
tion and  usually  disappeared  about  8  days  after  the  onset  of  the  flow. 
While  the  eruption  was  present,  the  patient  suffered  with  some  fever, 
headache,  lassitude,  insomnia,  and  constipation,  together  with  local  pain 
and  tenderness. 

Skin  Pigmentation. —  The  discoloration  of  the  eyelids  and  the  dark 
rings  under  the  eyes  so  frequently  observed  in  menstruating  women  are 
well  known.  Exaggerated  instances  of  this  discoloration,  in  which  the 
eyelids  assume  a  blackish  blue  color,  have  been  described  by  Leroy  de  Meri- 
court  under  the  name  of  "  chromokrinie."  He  explains  the  discoloration, 
as  due  to  the  exhalation  of  pigments  from  the  blood.  This  is,  of  course, 
purely  a  hypothesis. 

Pigmentation  may  also  be  noted  in  other  parts  of  the  body,  as  illustrated 
by  the  case  described  by  Barie.  His  patient  was  a  woman  of  neurotic 
temperament,  24  years  old.  For  5  months  menstruation  was  preceded  by 
the  appearance  on  both  surfaces  of  the  hand  of  peculiar  dark  yellowish 
spots.  The  two  hands  were  alternately  affected  each  month.  The  affected 
hand  perspired  freely,  with  tingling,  numbness,  etc.  With  the  disappear- 
ance of  menstruation,  the  spots  also  disappeared.  If  they  were  rubbed  with 
a  moist  linen  cloth,  they  assumed  a  light  brownish  color.  If  the  cloth  were 
saturated  with  oil,  the  spots  became  rusty  in  hue.  With  dilute  sulphuric 
acid  the  spots  became  almost  black. 

XXV 

LITERATURE 

Alexander.     Influence  of  Menstruation  on  Onset  and  Frequency  of  Epileptic 

Fits.     Med.  Press  and  Circ,  191 1,  92,  600. 
Baldwin.     Tachycardia  at  the  Menopause.     Brooklyn  Med.  J.,  1895,  9,  698. 
Barthel.     Ueber   das   Verhaken   der   Menstruation   bei    der  Verschiedenen 

Typhusformen.     Arch.  f.  Klin.  Med.,  1882-3,  32,  14. 
Baumgarten.     Rachen-  und  Kehlkopferkrankungen  in  Zusammenhang  mit 

Menstruationsanomalien.     Deutsch.  Med.  Wchnsch.,  1892,  18,  190. 
Benham.     Purpura  Hemorrhagica  Following  Menorrhagia.     Surg.,  Gyn.,  and 

Obst.,  1916,  23,  65. 
BiNET.     Crises  gastriques  premenstruelles  et  lithiase  biliaire.     Tribune  Med., 

1909,  41,  133. 
Bloch.     Ueber  den  Einfluss  der  Menstruation  bei  Verschiedenen  Internen 

Erkrankungen.     Basel,  1910. 
BoTTERMOND.     Ueber  die  Beziehungen  der  Weiblichen  Sexualorgane  zu  den 

Oberen  Luftwegen.     Monats.  f.  Geb.  u.  Gyn.,  1896,  4,  436. 
Brush.     Convulsive  Seizures  Associated  with  Postmenstrual  Gastrointestinal 

Disorders.     Jour.  A.  M.  A.,  1912,  59,  1777. 
BuRFORD.     Amenorrhea  Associated  with  Alcoholism.     Brit.   M.  J.,   1888,   i, 

1383- 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     311 

Chvostek.     Die  Menstruelle  Leberhyperamie.     Wien.  Klin.  Wchnsch.,  1909, 

22,  293. 
CoHN.     Zur  Casuistik  der  Amenorrhoe  bei  Diabetes  Mellitus  und  Insipidus. 

Zeitsch.  f.  Geb.  u.  Gyn.,  1887-88,  14,  194. 
CoTTE.     Tuberculose    inflammatoire,    dysmenorrhee,    d'origine    tuberculeuse. 

Gaz.  d.  Hop.,  Paris,  1909,  82,  1447. 
Davidson.     Ovarian  Epilepsy.     Edinb.  M.  J.,  1910,  4,  125. 
DiEPGEN  UND  Schroder.     Ueber  das  Verhalten  der  Weiblichen  Geschlechts- 

organe  bei  Hysterie,  Herzleiden,  und  Chlorose.     Zeitsch.  f.  Klin.  Med., 

1906,  59,  154. 
Dluski.     Menstrual  Fever  of  Tuberculous  Women.     Beitrage  zur  Klinik  der 

Tuberkulose,  191 1,  21,  153. 
DoLERis.     Affections  genitales  de  la  femme  et  maladie  de  Basedow.    J.  de  Med. 

de  Paris,  1895,  7.  465- 
DoRAN.     Chlorosis  and  Menstruation.     Tr.  Obst.  Soc.  London,  1889,  31,  119. 
Dunn.     A  Case  Illustrating  the  Bad  Effects  of  Establishment  of  Menstruation 

on  Course  of  Interstitial  Keratitis.     Arch,  of  Ophth.,  1895,  24,  353. 
Edebohls.     Menstrual  Dermatoses  of  Face.     Amer.  Gyn.  and  Obst.  J.,  1891-2, 

I,  55- 
Fellner.     Menstruelle  Leberhyperamie,  etc.     Med.  Klinik.,  1909,  5,  771. 

Friedrich.     Amenorrhoe  und  Phthisis.    Arch.  f.  Gyn.,  1914,  loi,  376. 

EscH.     Ueber  den  Einfluss  der  Influenza  auf  die  Funktionen  der  Weiblichen 

Genitalorgane,  etc.     Zentralb.  f.  Gyn.,  1919,  43,  161. 
Gemmell.     Menstruation  During  Measles  in  a  Girl  Aged  9.     Brit.  Med.  J., 

1892,  I,  502. 
Goldberg.     Uterusblutung  bei  Scorbut.     Centralb.  f.  Gyn.,  1893,  17,  1165. 
Gordon.     Epilepsy  in  Relation  to  Menstrual  Periods.     N.  Y.  Med.  J.,  1909, 

90,  733- 
Grafenburg.     Dysmenorrhoe    und    Tuberkulose.     Miinch.    Med.    Wchnsch., 

i9io»  57,  515- 
Greef.     Augenerkrankungen     bei     Menstruation     und     bei     Menstruations- 

erstorungen.     Monats.  f.  Geb.  u.  Gyn.,  1896,  3,  425. 
GuMPRiCH.     Der  Einfluss  der  Menstruation  auf  den  Blutbild  bei  Gesunden 

Individuen.     Beitrage  z.  Geb.  u.  Gyn.,  1914,  19,  435. 
HandfOrd.     Menstruation  and  Phthisis.     Brit.  M.  J.,  1887,  i,  153. 
Harrop  and  Mosenthal.     Influence  of  Menstruation  on  Acidosis  in  Diabetes 

Mellitus.     Bull.  Johns  Hop.  Hosp.,  1918,  29,  161. 
Haymann.     Menstrualstorungen  bei  Psychosen.    Ztschr.  f.  d.  Ges.  Neurol,  u. 

Psychiat,  1913,  15,  511. 
Hirschberg.     Ueber  Erblindung  nach  Blutverlust.     Centralb.  f.  Augenheilk., 

1892,  16,  258. 
Hollos.     Die  Tuberkulose  Atiologie  der  Menstruationsstorungen.    Deut.  Med. 

Wchnsch.,  1912,  38,  2407. 
Jerusalem.     Ueber  die   Beziehungen   zwischen   Menstruation  und   Erysipel. 

Wien.  Klin.  Rundschau,  1902,  16,  881. 
Klautsch.  Ueber  die  in  Folge  der  Cholera  Auftretenden  Pathologischen  Ana- 

tomischen       Veranderungen    in    den    Weiblichen    Generationsorgane. 

Miinch.  Med.  Wchnsch.,  1894,  41,  890;  910. 


312  MENSTRUATION  AND  ITS  DISORDERS 

KiSGH.     Sexual  Life  of  Woman  in  its  Physiological,  Pathological,  and  Hy- 
gienic Aspects.     Trans,  by  M.  E.  Paul,  1910. 
-. Ueber  Tachycardia  der   Menopause.     Prag.   Med.   Wochensch.,   1891, 

16,  113. 
Lewinsohn.     Ueber    den   Zusammenhang   von    Magen-    und    Frauenleiden. 

Berlin,  1909. 
Macht.     Tuberculosis  and  Menstruation.     Amer.  J.  Med.  Sci.,  1910,  140  ,839. 
Mackenzie.     Menstruation  in  the  Insane.     J.  Ment.  Sc.  (London),  1908,  54, 

116. 
Meirovvsky     und     Frankenstein.      Amenorrhoe     und     Ter-tiare     Syphilis. 

Deutsch.  Med.  Wchnsch.,  1910,  36,  1444. 
MoNHEiM.     Menstruation  bei  Herzfehlern.     Ann.  d.  Stadt.  Allgem.  Kranken- 

haus  zu  Miinchen,  (1909-10)  1913,15,673. 
Morgan.     Menstrual  Arthritis.     Amer.  J.  Obst.,  1907,  56,  207. 
MuLLER.     Relations  of   Female  Reproductive  Organs  to  Internal   Diseases. 

Amer.  J.  Med.  Sc,  1908,  86,  313. 
Napier.     Blindness  and  Amenorrhea.     Brit.  Gyn.  J.,  1896,  46,  176. 
Neuman.     Ueber  Beziehungen  von   Gelenkkrankheiten  zur  KlimaCterischen 

Lebensepoche.     Med.  Klin.,  1908,  4,  407. 
Opel.     Ueber  Menstrualexantheme.     Leipz.,  1908. 
Osler  and  McCrae.     System  of  Medicine.     9th  ed.,  1920. 
Passower.     Ueber    Morphinismus    und    dessen    Einfluss    auf    Sexualsphare. 

Centralb.  f.  Gyn.,  1893,  17,  33. 
Plonies.     Die  Gegenseitigen  Beziehungen  der  Menstruation  und  der  Magener- 

krankungen,  etc.     Arch.  f.  Verdauungskr.,  1908,  14,  670. 
PopoFF.     Frauenherz  und  Klimax.     Therap.  d.  Gegenw.,  1908,  49,  439. 
Riebold.     Ueber  Mensitruelles  Fieber  und  die  Bedeutungen  der  Menstruation 

fijr  die  Atiologie  Innerer  Krankheiten.     Miinch,  Med.  Wchnsch.,  1906, 

53,  576. 
Ueber    Periodische    Fieberbewegungen    mit    Rheumatischen    Erschei- 

nungen  bei  Jungen  Madchen  (Rekurrierend  Rheumatoides  Ovulations- 

fieber).     Deut.  Arch.  f.  Klin.  Med.,  1908,  93,  15. 
Rosenstrauss.     Menstruation  und  Innere  Krankheiten.     Berlin,  1912.  .  ' 

Ross.     Menstruation  and  Insanity.     J.  Ment.  Sc,  1909,  55,  270. 
VON  Rosthorn  und  Lenhartz.     Die  Beziehungen  der  Weiblichen  Geschlechts- 

organe  zu  Inneren  Erkrankungen.     Deutsch.  Med.  Wchnsch.,  1908,  34, 

761. 
ScHUTz.     Ueber  den  Einfluss  der  Cholera  auf  Menstruation,  etc.    Centralb.  f. 

Gyn.,  1894,  18,  II 38. 
Senator.     Ueber  Menstruelle  Gelbsucht.     Berl.  Klin.  Wchnsch.,  1872,  9,  615. 
Slocum.     Ovaritis    in    Typhoid    Fever,    with    Consequent   Amenorrhea    and 

Sterility.     South.  Med.  J.,  1915,  8,  706. 
Stephenson.     On  Relation  between  Chlorosis  and  Menstruation.     Tr.  Obst. 

Soc.  Lond.,  1889,  31,  104. 
Stolz.     Die  Beziehungen  der  Akuten  Infektionskrankheiten  zu  den  Weiblichen 

Geschlechtsorganen.     Klin.-therap.  Wchnsch.,  (Berl.)  191 3,  20,  541. 
Swanberg  and  Haynes.     Menstrual  Disturbances  in  Feeble  Minded.     Jour, 

Ment.  and  Nerv.  Dis.,  1919,  50,  224. 
Tait.     Climacteric  Diabetes  in  Women.     Practitioner,  1886,  36,  401. 


RECIPROCAL  RELATIONS  OF  MENSTRUATION  AND  DISEASES     313 

Taussig.     Uterus  and  Stomach ;    their  Anatomic,  Physiologic  and  Pathologic 

Relationship.     Jour.  A.  M.  A.,  1908,  51,  1005. 
Theilhaber.     Die     Beziehungen     der     Basedowischen     Krankheit     zu     den 

Veranderungen    der    Weiblichen    Geschlechtsorgane.      Arch.    f.    Gyn., 

1895,  49,  57. 
Thoma.     Ueber  ein  Fall  von  Menstrualpsychose  mit  Periodischer  Struma  und 

Exophthalmos.     Allg.  Zeitsch.  f.  Psychiat.,  1894,  2,  590. 
TowNSEND.     Haemophilia  at  the  First  Menstrual  Period.     Bost.   M.  and   S. 

Jour.,  1890,  123,  516. 
ViRCHOW.     Ueber  die  Chlorosis  und  die  damit  Zusammenhangenden  Anoma- 

lien  im  Gefassapparate.     Beitrage  z.  Geb.  u.  Gyn.,  1870,  S.,  323.       [_ 
VoiGT.     Ueber  den  Einfluss  der  Variola  auf  Menstruation,  etc.     Centralb.  £! 

Gyn.,  1894,  18,  1241.  ^ 

Wallin.     Post-climacteric  Uterine  Hemorrhage  due  to  Relative  Hypothyroid- 
ism.    Jour.  A.  M.  A.,  1908,  51,  2157. 
Williams.     Cardiopathies  of  the  Menopause.     Clin.  J.  London,  1908-9,  2y}ii 

325- 
WoLPE.     tjber  Steigerung  der  Sekretion  und  der  Aziditat  des  Magensaftes. 

wahrend  der  Menstruation.     Deutsch.  Med.  Wchnsch.,  1908,  34,  2208. 
WoRONYTSCH.     Zur    Frage    der    Menstruellen     Schilddrussenvergrosserung. 

Wien.  Klin.  Wchnsch.,  1914,  2y,  937. 
ZiCKGRAF.     Zusammenhang  zwischen  Dysmenorrhoe  und  Tuberculose.     Ztschr. 

f.  Tuberk.,  1910,  16,  57. 


CHAPTER  XXVI 
THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS 

Introductory. —  Although  Claude  Bernard  is  commonly  credited  with 
the  discovery  of  the  internal  secretions,  it  was  Brown-Sequard,  some  thirty- 
four  years  later,  who  first  directed  attention  to  the  therapeutic  possibilities 
of  organ  extracts.  On  a  memorable  evening,  June  ist,  1889,  he  announced 
the  remarkable  rejuvenating  effects  produced  in  himself  by  the  subcutaneous 
injection  of  testicular  extract.  The  unwarranted  hopes  produced  by  this 
enthusiastic  report  have  long  since  been  dissipated.  Furthermore,  the 
miraculous  results  which  were  claimed  for  this  early  experiment  in  organo- 
therapy are  perhaps  chiefly  responsible  for  the  unreasonable  attitude  of  many 
clinicians  toward  the  whole  subject  of  organotherapy.  There  are  many 
whose  use  of  these  substances  is  based,  either  consciously  or  unconsciously, 
upon  the  notion  that  their  therapeutic  effects  are,  or  should  be,  more  or  less 
si>ecific.  Unless  they  are  •—  unless,  for  example,  the  success  in  a  given  case 
is  at  least  comparable  to  the  brilliant  results  of  thyroid  treatment  in 
myxedema  —  there  is  a  tendency  to  be  discouraged  and  to  look  upon  the 
whole  treatment  as  unsatisfactory. 

As  a  matter  of  fact,  organotherapy  should  be  looked  upon  as  only  a 
species  of  drug  treatment.  Like  the  drugs  which  we  use  in  combating 
disease,  the  organ  extracts  are  definite  chemical  substances.  In  the  case  of 
at  least  one  of  them,  adrenalin,  we  know  the  exact  chemical  composition. 
Only  a  relatively  small  proportion  of  drugs  in  common  use  —  quinin,  mer- 
cury and  salvarsan  are  the  best  examples  —  are  specifics  against  certain 
diseases.  The  great  majority  are  useful  because  they  are  effective  against 
certain  individual  manifestations  of  disease.  In  the  same  way,  the  organ 
extracts,  with  the  single  exception  of  thyroid  extract,  are  often  employed 
to  exert  an  adjuvant  rather  than  a  specific  effect.  Viewed  in  this  light, 
and  considering  the  relative  newness  and  lack  of  development  of  this  form 
of  medication,  there  would  seem  to  be  no  justification  for  discouragement 
with  the  results  so  far  achieved. 

Organ  Extracts  Which  May  Be  Used  in  the  Treatment  of 
Menstrual  Disorders 

General  Considerations. —  The  female  generative  apparatus  is  more 
or  less  closely  linked  up  with  a  number  of  endocrine  glands.  (Chapter 
XXIV.)      Most  important,  of  course,  is  the  ovary.     Other  ductless  glands 

314 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  315 

which  influence  the  reproductive  activities  are  the  thyroid,  the  pituitary,  the 
suprarenals,  the  thymus  and  the  pineal  body.  It  is  not  surprising  that 
extracts  prepared  from  all  these  organs  have  been  employed  in  the  treat- 
ment of  disorders  of  menstruation.  Each  has  recently  explained  the  para- 
doxical results  so  often  observed  with  organotherapy  on  the  basis  that  the 
action  of  the  organ  extracts  is  often  general  rather  than  specific,  due  to 
the  presence  in  them  of  protein  bodies.  In  the  case  of  extracts  from  the  supra- 
renal, thymus,  and  pineal  bodies,  the  results  are  as  yet  so  vague  and  uncer- 
tain that  it  would  seem  unprofitable  to  discuss  them  here.  I  believe  it  will 
be  accepted  that  in  the  organotherapy  of  menstrual  disorders,  the  physician's 
armamentarium  may,  for  practical  purposes,  be  limited  to  extracts  made 
from  the  thyroid,  ovary  and  the  pituitary  body. 

Unfortunately,  the  various  commercial  preparations  of  these  substances 
vary  so  much  in  potency  that  it  would  seem  unwise,  in  the  present  discus- 
sion, to  be  too  dogmatic  in  suggesting  a  definite  dosage  of  these  extracts. 
The  lack  of  standardization  is  particularly  conspicuous  in  the  case  of  the 
many  forms  of  ovarian  or  corpus  luteum  extracts  which  have  been  put 
upon  the  market.  For  obvious  reasons,  it  would  be  in  poor  taste  to  discuss 
by  name  the  preparations  of  various  reliable  pharmaceutical  firms,  especially 
since  an  abundance  of  literature  on  each  product  is  usually  easily  obtainable. 
Only  the  general  principles  governing  this  method  of  treatment  need  be 
here  considered. 

Thyroid  Extract. —  In  many  ways  the  most  satisfactory  of  all  the- 
organic  extracts  in  the  treatment  of  menstrual  disorders  is  thyroid  extract. 
Hertoghe's  statement  that  "  the  best  method  of  stimulating  the  ovary, 
testicle,  suprarenal,  and  hypophysis  is  by  way  of  the  thyroid,  which  governs 
and  controls  all  the  internal  secretory  organs,"  is  perhaps  not  capable  of 
scientific  proof,  but  it  has  much  to  commend  it  from  a  practical  point  of 
view.  While  theoretically  the  influence  of  thyroid  should  be  less  direct 
and  less  potent  in  menstrual  disorders  than  that  of  ovarian  substance,  these 
considerations  are  more  than  counterbalanced  by  the  greater  reliability  of 
thyroid  preparations,  by  our  more  precise  knowledge  of  their  pharmaco- 
dynamics, and  by  the  greater  potency  of  their  action  in  general.  A  great 
advantage  in  thyroid  medication  is  the  fact  that  administration  of  the 
extract  by  mouth,  most  commonly  in  the  form'  of  the  well  known  tablets, 
yields  eminently  satisfactory  results. 

Pituitary  Extract. —  The  now  well  known  pituitary  extract,  prepared 
commercially  under  a  variety  of  names  (pituitrin,  hypophysin,  infundibulin, 
etc.),  is  derived  from  the  posterior  lobe  of  the  hypophysis.  Its  value  in  an 
increasing  number  of  conditions  is  well  recognized.  Most  brilliant,  per- 
haps, have  been  its  results  in  such  obstetrical  conditions  as  uterine  inertia, 
postpartum  hemorrhage,  etc.  Its  value  as  a  diuretic  and  as  an  entero- 
kinetic,  and  perhaps  even  more,  its  remarkable  virtue  in  the  control  of 
diabetes  insipidus,  are  also  worthy  of  note.  As  yet  it  can  hardly  be  said 
to  have  earned  a  place  of  much  importance  in  the  treatment  of  menstrual 


I3I6  MENSTRUATION  AND  ITS  DISORDERS 

disorders,  even  though  its  employment  in  certain  of  the  latter  is  based  upon 
Very  rational  indications.  Encouraging  results  have,  however,  been  re- 
ported by  a  number  of  investigators,  and  it  is  possible  that  a  wider  experi- 
ence may  demonstrate  that  it  has  a  definite  place  in  the  treatment  of  certain 
disorders  of  the  menstrual  function. 

It  is  prepared  in  both  a  solid  form,  for  administration  by  mouth,  and  in 
the  form  of  the  solution,  suitable  for  hypodermic  administration.  So  far 
the  results  of  the  ingestion  method  have  been  distinctly  disappointing. 
AMiether  this  is  due  to  defective  methods  of  preparation  or  to  a  nullifying 
effect  of  the  gastro-intestinal  secretions  cannot  be  stated.  By  far  the  most 
effective  method  of  giving  pituitary  extract,  however,  is  by  the  hypodermic 
method,  for  which  purpose  the  substance  is  commercially  prepared  in 
ampoules  suitable  for  hypodermic  injection.  Most  commonly  the  injections 
are  made  subcutaneously,  but  by  some  the  intravenous  method  is  highly 
recommended. 

In  addition  to  the  posterior  lobe  extracts,  preparations  of  the  anterior 
lobe  alone,  as  well  as  of  the  entire  pituitary,  are  available  commercially. 
They  are  prepared  in  either  powdered  or  tablet  form. 

Extract  of  Ovary  or  Corpum  Luteum. —  Since  the  ovary  is  the  organ 
which  directly  controls  the  menstrual  function,  it  would  seem  that  quantita- 
tive disorders  of  the  latter  would  most  logically  be  treated  by  administration 
of  the  active  principle  of  the  ovary.  While  in  certain  menstrual  disorders 
ovarian  extract  has  yielded  results  which  are  very  encouraging,  in  other 
types,  as  will  be  shown,  the  results  have  been  more  or  less  disappointing. 
The  probabilities  are  that  at  least  two,  and  perhaps  more,  hormones  are 
produced  in  the  ovary.  It  seems  to  have  been  fairly  well  established  that 
the  hormone  which  is  responsible  for  the  occurrence  of  menstruation  is 
formed  by  the  corpus  luteum  (Chapter  VII),  The  internal  secretion  which 
is  concerned  with  the  fixation  of  the  ovum  in  the  first  portion  of  pregnancy, 
on  the  other  hand,  more  probably  is  derived  from  the  so-called  interstitial 
glands,  i.  e.,  the  thecalutein  cells  of  atretic  follicles,  or  from  the  paralutein 
cells  of  the  corpus  luteum,  which  I  described  in  a  recent  paper.  As  to  this 
point,  however,  there  is  as  yet  no  definite  proof. 

Finally,  we  must  not  overlook  the  fact  that,  according  to  the  best  evi- 
dence, the  ovaries  in  females,  like  the  testes  in  males,  determine  the  develop- 
ment of  the  so-called  secondary  sexual  characteristics,  such  as  the  height 
and  configuration  of  the  body,  the  distribution  of  hair,  the  character  of  the 
voice,  the  development  of  the  breasts,  etc.  What  portion  of  the  ovary  is 
concerned  with  this  function  is  not  known.  From  the  fast  that  corpora 
lutea  ordinarily  are  not  present  until  menstruation  is  inaugurated,  it  seems 
possible  that  the  stroma  of  the  ovary  may  be  the  important  element  in  this 
respect.  At  any  rate,  it  would  seem  justifiable  to  conclude  that  the  con- 
stituent of  the  ovary  most  directly  concerned  with  the  function  of  menstrua- 
tion is  the  corpus  luteum,  and  that  other  ovarian  elements  are  probably 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  317 

more  important  in  the  regulation  of  such  phenomena  as  growth,  determina- 
tion of  the  secondary  characteristics,  etc. 

I  mention  these  matters  because  they  appear  to  throw  some  Hght  on  the 
much  discussed  question  of  whether  we  should  employ  extracts  made  from' 
the  corpus  luteum  alone  or  from  the  entire  substance  of  the  ovary.  Based 
on  the  above  considerations,  I  have  personally  been  inclined  to  the  use  of 
corpus  luteum  preparations  in  the  management  of  disturbances  revolving 
about  the  menstrual  function.  On  the  other  hand,  in  cases  which  involve 
endocrinal  relationships  more  profoundly,  and  especially  those  in  which 
there  is  some  disturbance  of  growth  or  body  type,  I  have  leaned  toward 
extracts  made  from  the  whole  ovary.  Whether  or  not  this  distinction  is 
well  taken  it  is  difficult  to  decide,  especially  in  view  of  the  fact  that  the 
results  in  all  forms  of  ovarian  therapy  are  unfortunately  still  very  inconstant. 

Both  the  ovarian  and  the  corpus  luteum  extracts  are  prepared  by  various 
pharmaceutical  firms  in  the  form  of  tablets  or  capsules,  suitable  for  admin- 
istration by  mouth  (lutein,  extract  corpora  lutea,  etc.).  A  soluble  form 
for  administration  hypodermically  (intramuscularly)  has  also  been  pre- 
pared. Good  results  from  its  use  have  been  reported  by  Hirst  and  others, 
but  this  form  of  medication  has  not  as  yet  achieved  a  very  wide  vogue.  Its 
results  in  my  own  hands  have  been  encouraging.  ;i:l- 

Recently  Graves  has  suggested  the  employment  of  "  ovarian  residue," 
prepared  from  the  ovary  after  separation  of  the  corpora  lutea.  While  it  is 
too  early  to  draw  conclusions  as  to  its  value,  there  is  little  reason  to  expect 
that  it  will  prove  any  more  effective  than  other  ovarian  preparations. 

Some  authors,  as  well  as  some  manufacturers,  lay  much  stress  on  the 
superiority  of  preparations  made  from  the  corpora  lutea  of  pregnant, as 
compared  with  non-pregnant  animals.  The  correctness  of  this  view  is  open 
to  question,  especially  when  we  consider  that  the  corpus  luteum  of  preg- 
nancy, in  spite  of  its  large  size,  is  normally  associated  with  an  absence  of 
menstruation.  There  can  be  little  doubt  that  the  physiologic  role  of  the 
corpus  luteum  hormone  varies  at  different  stages,  as  asserted  by  Seitz  and 
his  coworkers.  This  investigator  isolated  from  the  corpus  luteum  of  beef 
ovaries,  at  different  stages  of  its  development,  two  substances  of  almost 
opposite  physiological  action.  One  of  these,  which  he  calls  lipamin,  is  said 
to  stimulate  the  growth  of  both  the  internal  and  external  genitalia  in  animals, 
while  its  subcutaneous  injection  in  amenorrheic  women  wnll  bring  on  the 
menses. .  This  substance  predominates  in  the  young  corpus  luteum.  The 
second  substance,  on  the  other  hand,  which  Seitz  calls  luteolipoid,  appears 
to  act  as  an  inhibitor  of  the  menstrual  function,  and  is  found  in  large 
amounts  in  the  later  stages  of  the  corpus  luteum. 

Types  of  Menstrual  Disorder  in  Which  Organotherapy  is 

Indicated 

Amenorrhea. —  Menstrual  and  Developmental  Disorders  of  Pur 

■     ■  J  -  - .  -.  f 

eERTY.r^- During  the  first  year  or  two  of  menstrual  life,  periods -of  arrienqrr' 


318  MENSTRUATION  AND  ITS  DISORDERS 

rhea  are  commonly  observed,  lasting  from  two  to  several  months.  This  may 
occur  even  in  girls  who  are  entirely  healthy  in  every  respect,  i,  e.,  who  are 
not  suffering  from  such  conditions  as  anemia,  tuberculosis,  etc.  This 
physiological  amenorrhea  requires  no  treatment  except  perhaps  reassurance 
of  the  patient.  If,  on  the  other  hand,  menstruation  does  not  appear  at  the 
normal  age,  and  if  such  a  primary  amenorrhea  is  associated  with  other 
evidences  of  lack  of  development,  it  is  reasonably  certain  that  there  is  some 
disturbance  of  endocrine  function.  Unfortunately  it  is  not  always  possible, 
in  the  present  state  of  our  knowledge,  to  determine  just  what  the  endocrine 
defect  is.  In  the  majority  of  cases,  it  is  probable  that  the  fault  lies  with 
the  ovaries  or  the  pituitary,  and  hence  administration  of  extracts  from 
these  glands  is  indicated.  For  reasons  which  I  have  already  indicated,  my 
preference  in  this  group  of  cases  is  for  extracts  made  from  the  entire  ovary 
rather  than  from  the  corpus  luteum  alone. 

In  certain  cases  delayed  puberty  appears  to  be  a  manifestation  of  hypo- 
thyroidism, although,  as  will  be  emphasized  later,  the  latter  condition  more 
frequently  causes  menorrhagia  than  amenorrhea.  Finally,  in  cases  which 
fail  to  respond  to  other  organic  extracts,  some  resort  to  the  use  of  thymus 
or  pineal  gland  substances,  although  the  results  are  rarely  striking.  On 
the  whole,  it  is  obvious  that  the  treatment  of  the  menstrual  and  develop- 
mental disorders  of  puberty  by  means  of  ductless  gland  extracts  is  as  yet 
extremely  unsatisfactory,  owing  to  our  lack  of  knowledge  of  the  pathologic 
physiology  of  these  conditions.  The  use  of  extracts  in  these  disorders  is 
almost  entirely  empirical  and  often  disappointing. 

On  the  other  hand,  organotherapy  in  cases  of  this  type,  is,  in  my  judg- 
ment, infinitely  safer  than  the  administration  of  emmenagogues.  The  ex- 
tracts themselves  are  of  course  not  emmenagogues,  except  in  the  very 
indirect  sense  that  they  may  correct  the  endocrine  defect  which  is  responsible 
for  the  amenorrhea.  On  the  other  hand,  the  employment  of  emmenagogues, 
so  frequently  resorted  to  in  the  past,  is  based  on  the  theory  that  they  give 
rise  to  a  pelvic  hyperemia  which  promotes  menstruation.  Even  if  this  were 
true,  it  would  be  hard  to  conceive  how  such  an  artificial  pelvic  hyperemia 
could  induce  the  occurrence  of  the  normal  rhythmic  menstrual  flow.  Fur- 
thermore, the  prolonged  administration  of  such  drugs,  through  the  per- 
sistent pelvic  congestion  which  they  entail,  may  easily  predispose  to  serious 
pelvic  discomfort  and  disease. 

Functional  Amenorrhea  of  Later  Life. —  Much  of  what  has  been 
said  with  regard  to  the  functional  amenorrhea  of  puberty  applies  also  to 
the  functional  amenorrhea  of  later  life.  I  need  scarcely  say  that  we  are  not 
here  concerned  with  those  cases  which  are  clearly  secondary  to  such  debil- 
itating systemic  conditions  as  tuberculosis  or  anemia.  The  most  common 
type  of  functional  amenorrhea  is  that  which  is  associated  with  adiposo- 
genital dystrophy  (dystrophia  adiposogenitalis)  or  Frohlich's  syndrome 
(Chapter  XXIV).  I  shall  not  go  into  the  discussion  here  of  this  interest- 
ioff  condition  except  to  say  that  its  two  principal  characteristics  are  obesity 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  319 

and  sexual  hypoplasia.  The  latter  manifests  itself  most  conspicuously  in  the 
woman  by  scantiness  or  absence  of  the  menstrual  flow.  Practically  all  the 
older  text  books  of  gynecology  mentioned  adiposity  as  a  cause  of  amenor- 
rhea. Instead  of  adiposity  causing  amenorrhea,  or  vice  versa,  as  some 
have  believed,  we  know  now  that  both  conditions  are  themselves  the  result 
of  the  same  underlying  cause,  i.  e.,  deficiency  of  the  pituitary  body,  as  has 
been  so  clearly  demonstrated  by  Gushing  and  his  coworkers. 

The  rational  treatment  of  amenorrhea  of  this  type  would  seem  to  be  the 
administration  of  pituitary  substance  to  counteract  the  hypopituitarism 
which  has  been  shown  to  be  responsible  for  the  condition.  Although  the 
amenorrhea  in  patients  of  this  type  is  perhaps  in  an  immediate  sense  of 
ovarian  origin,  it  would  seem  that  the  primary  defect  is  in  the  pituitary 
hormone,  and  that  treatment  should  be  directed  to  the  correction  of  this 
latter  deficiency.  The  results  yielded  by  such  medication  have  not,  how- 
ever, been  altogether  satisfactory,  partly,  perhaps,  owing  to  the  uncertainty 
which  still  exists  as  to  the  relative  importance  of  the  anterior  and  posterior 
lobes  of  the  pituitary  in  bringing  about  the  syndrome  (Chapter  XVIII). 

In  accordance  with  the  formerly  predominant  opinion  on  this  point,  the 
extract  which  was  at  first  most  generally  used  was  that  from  the  posterior  lobe. 
Fromme,  who  was  a  pioneer  in  this  form  of  treatment,  reported  encouraging 
results  in  a  series  of  12  cases  of  amenorrhea  treated  in  this  way.  In  5  of 
these  the  treatment  failed,  and  in  2  its  success  was  doubtful.  In  the 
remaining  5,  however,  the  return  of  menstruation  was  prompt.  Even  in 
those  in  which  the  amenorrhea  persisted,  the  subjective  symptoms  are  said 
to  have  been  greatly  ameliorated.  Hofstatter  has  also  reported  very  favor- 
able results  from  the  use  of  pituitary  substance  in  a  large  series  of  cases  of 
amenorrhea. 

Similar  results  are  reported  in  small  series  of  cases  by  Fries,  Zoppritz, 
and  Kosminski.  The  plan  of  treatment  recommended  by  the  last  named 
author  consists  in  injecting  i  c.cm.  of  the  soluble  extract  (pituitrin,  pitu- 
glandol,  etc.)  on  alternate  days.  In  one  case  of  amenorrhea  thus  treated, 
a  series  of  ten  injections  was  followed  by  a  profuse  uterine  bleeding.  He 
has  never  given  more  than  twenty  consecutive  injections  to  any  patient. 
He  advises  frequent  careful  examination  of  the  urine,  on  account  of  the 
danger  of  glycosuria. 

As  already  intimated,  the  extract  of  the  anterior  pituitary  lobe,  rather 
than  the  posterior  lobe,  is  now  considered  by  most  authors  to  be  indicated 
in  the  treatment  of  these  cases.  Thus,  Roblee  has  recently  reported  a 
successful  result  from  the  use  of  the  anterior  lobe  extract  in  a  case  of 
adiposogenital  dystrophy  occurring  in  a  male.  Similar  observations  have 
been  made  by  others. 

In  my  own  experience,  the  best  results  in  the  treatment  of  adiposogenital 
dystrophy  have  been  noted  from  the  use  of  thyroid  extract  and  the  various 
forms  of  ovarian  extract.  As  regards  the  latter,  I  may  say  that  my  prefer- 
ence has  been  for  extracts  made  from  the  corpus  luteum  alone,  although 


320  MENSTRUATION  AND  ITS  DISORDERS 

I  am  frank  to  say  that  the  results  have  not  been  very  different  from  those 
observed  from  the  use  of  extracts  of  the  entire  ovary.  As  a  matter  of  fact, 
it  is  rare  to  note  reestabhshment  of  the  menses  from  either  form  of  medi- 
cation. Furthermore,  contrary  to  what  one  might  theoretically  expect,  there 
appears  to  be  very  little  influence  exerted  by  either  ovarian  or  corpus  luteum 
substance  on  the  obesity  characteristically  associated  with  the  amenorrhea 
of  these  cases.  Often,  as  a  matter  of  fact,  there  is  a  tendency  to  increase 
rather  than  to  decrease  the  body  weight. 

The  organ  extract  which,  on  the  whole,  I  have  found  most  valuable  in 
the  treatment  of  adiposogenital  dystrophy,  as  well  as  of  other  forms  of 
functional  amenorrhea,  is  thyroid  extract.  This  is  true  even  of  those  cases 
where  there  are  no  clinical  indications  of  hypothyroidism.  It  is  difficult  to 
explain  the  good  results  not  infrequently  obtained  from  thyroid  extract  in 
these  cases,  nor  will  they  be  susceptible  of  explanation  until  our  knowledge 
of  endocrine  relationships  is  far  more  advanced  than  it  now  is.  The  admin- 
istration of  thyroid  in  proper  dosage  is  often  followed  by  reappearance  of 
the  menses,  and  practically  always  by  a  more  or  less  marked  reduction  in 
body  weight. 

The  average  dosage  of  thyroid  extract  in  these  cases  of  mild  hypothy- 
roidism should  never  exceed  five  grains  a  day,  and  in  most  cases  it  will  be 
much  less.  The  patient  should  be  observed  at  least  once  a  week,  to  deter- 
mine her  tolerance  and  to  make  sure  that  no  harm  is  resulting  from  the  use 
of  the  thyroid.  The  principal  criterion  should  be  the  condition  of  the  heart. 
If  the  heart  rate  is  not  accelerated,  one  may  feel  assured  that  no  hyperthy- 
roidism exists.  If,  on  the  other  hand,  it  is  found  that  the  use  of  the  thyroid 
is  accompanied  by  a  gradually  mounting  pulse  rate,  together  with  nervous- 
ness, tremor,  etc.,  the  dose  should  be  cut  down.  For  prolonged  administra- 
tion one  or  two  grains  a  day  is  often  sufficient. 

An  important  guide  to  the  action  of  thyroid  extract  is  its  effect  upon  the 
body  weight,  which  is  practically  always  diminished.  This,  as  is  well  known, 
is  the  result  of  a  stimulating  effect  upon  the  oxidation  processes  in  the  body. 
It  is  seldom  advisable  for  the  patient  to  lose  weight  at  a  faster  rate  than  two 
or  three  pounds  a  week.  The  total  loss  of  weight  depends,  of  course,  upon 
the  initial  body  weight  and  upon  the  duration  and  intensity  of  the  treatment, 
as  well  as  upon  such  adjuvant  measures  as  dietetic  regulation,  exercise, 
etc.  In  suitable  cases  the  treatment  yields  striking  results  within  a  month, 
menstruation  becoming  normal  and  the  health  being  improved  In  every  way. 
Instead  of  discontinuing  the  thyroid  medication  abruptly,  it  is  wise  to 
diminish  the  dosage  gradually,  and  to  keep  up  small  doses  for  a  considerable 
period  of  time. 

The  probability  that  most  of  these  cases  are  to  be  looked  upon  as  really 
of  pluriglandular  origin,  and  the  uncertainty  of  action  of  the  various  indi- 
vidual extracts  has  led  many  to  resort  to  polytherapeutic  measures  in  the 
management  of  these  cases.  Thus,  in  adiposogenital  dystrophy,  I  have 
often  used  thyroid  and  corpus  luteum  extracts  together  with  good  results. 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  321 

There  would  seem  to  be  much  justification  for  this,  especially  since  the  addi- 
tion to  the  thyroid  of  corpus  luteum  in  any  ordinary  amount  is  unattended 
with  danger.  Certain  proprietaries  are  stated  to  contain  extracts  of  a  num- 
ber of  the  ductless  glands  in  varying  proportions  and  amounts.  The  "  gun- 
shot "  nature  of  some  of  these  polyglandular  mixtures  indicates  how  im- 
portant a  role  empiricism,  based  on  a  few  small  molecules  of  fact,  plays  in 
our  modern  efforts  at  organotherapy. 

Uterine  Hemorrhage. —  In  a  certain  proportion  of  cases,  menorrhagia 
or  metrorrhagia  at  the  time  of  puberty  is  due  to  definite  pathological  lesions 
in  the  pelvic  organs,  such  as  disease  of  the  endometrium,  neoplasms  of 
the  ovary,  etc.  With  this  type  of  bleeding  we  are  not  here  concerned. 
Very  frequently,  however,  hemorrhage  at  this  period  of  life  occurs  in  the 
entire  absence  of  an,y  demonstrable  pelvic  disease  (Chapter  XXII).  As  a 
rule,  it  is  the  result  of  one  form  or  another  of  endocrine  disturbance,  most 
frequently  in  the  thyroid  gland  or  the  gonads.  I  know  of  no  reliable  obser- 
vations incriminating  any  of  the  other  ductless  glands,  although  it  is  of 
course  quite  possible  that  they  may  at  times  play  a  role  in  the  causation  of 
uterine  hemorrhage. 

With  regard  to  the  thyroid,  there  has  been  some  difference  of  opinion  as 
to  the  effects  of  hyper-  and  hypothyroidism  upon  the  menstrual  function. 
The  weight  of  evidence  supports  the  view  that,  generally  speaking,  hyper- 
function  of  the  thyroid,  as  in  Graves'  disease,  tends  toward  diminishing  the 
amount  of  the  menstrual  fllow,  while  on  the  other  hand,  hypothyroidism 
is  more  likely  to  be  associated  with  excessive  menstruation.  This  is  the 
view  which  is  supported  by  Hertoghe,  as  well  as  by  Sehrt.  The  latter 
found,  in  a  series  of  55  cases  of  uterine  bleeding  of  "idiopathic"  origin, 
fully  38  which  exhibited  definite  signs  of  hypothyroidism.  On  the  other 
hand,  there  can  be  no  question  that  at  times  menorrhagia  is  observed  in 
women  with  undoubted  hyperthyroidism,  as  in  some  cases  of  well  marked 
Graves'  disease.  These  apparent  paradoxes  are,  of  course,  not  uncommon 
in  the  field  of  endocrine  pathology.  As  yet  no  satisfactory  explanation  can 
be  offered  for  them,  although  it  is  probable  that  many,  perhaps  most,  of 
the  recognized  clinical  syndromes  are  the  result  of  pluriglandular  rather 
than  uniglandular  involvement.  Hence  the  not  infrequent  overlapping  of 
symptoms. 

The  menorrhagia  of  hypothyroidism  is  at  times  observed  in  girls  in  whom 
menstruation  has  appeared  late  and  in  whom  there  are  other  evidences  of 
tardy  development.  The  diagnosis  of  its  hypothyroid  origin  is  usually  sug- 
gested by  the  existence  of  a  more  or  less  complete  array  of  the  symptoms 
which  are  now  generally  recognized  as  indicative  of  defective  function  of 
the  thyroid.  These  I  shall  not  detail  here,  except  merely  to  emphasize  the 
importance  in  this  connection  of  obesity;  the  transitory  "white  indolent 
edema  "  which  may  be  noted  in  the  eyelids,  cheeks,  feet  or  fingers,  and 
which  does  not  pit  on  pressure ;  the  harsh,  dry  skin,  with  tendency  to  chilli- 
ness ;  and  the  hirsute  derang-ements,  such  as  falling  out  of  the  hair  or  thin- 


322  MENSTRUATION  AND  ITS  DISORDERS 

ness  of  the  eyebrows,  especially  in  their  outer  third.  (For  further  discus- 
sion see  Chapters  XXII  and  XXIV.) 

The  treatment  of  uterine  bleeding  of  hypothyroid  origin  is  simple 
enough,  consisting  essentially  in  the  administration  of  thyroid  extract.  It 
must  not  be  forgotten  that  this  substance  is  a  powerful  agent,  whose  use 
must  always  be  rigidly  supervised  by  the  physician.  Excessive  dosage 
gives  rise  to  the  characteristic  symptoms  of  hyperthyroidism,  such  as  tachy- 
cardia and  tremor.  When  abuse  of  the  drug  is  protracted,  serious  injury 
may  be  inflicted  upon  the  cardiovascular  system.  Seldom  should  the  dosage 
exceed  five  grains  a  day.  As  a  rule  it  will  be  considerably  less,  especially 
when  the  administration  of  the  extract  is  to  be  kept  up  for  a  long  time. 

Pituitary  extract  has  also  been  employed  in  the  treatment  of  uterine  hem- 
orrhage. When  the  latter  is  due  to  atony  of  the  uterine  muscle,  as  in  post- 
partum or  postabortive  cases,  the  results  are,  as  is  well  known,  highly 
gratifying.  This  can  not  be  said  of  uterine  hemorrhages  of  other  types. 
The  feeding  of  pituitary  extracts  by  mouth  is  attended  with  as  little  success 
in  the  usual  case  of  non-obstetrical  uterine  hemorrhage  as  in  most  other 
conditions  in  which  it  has  been  used.  Somewhat  more  satisfactory  appear 
to  have  been  the  results  when  pituitary  extract  has  been  given  subcutaneously 
or  intravenously.  The  latter  method,  in  the  hands  of  Kalledey,  is  stated  to 
have  yielded  good  results.  Such  reports,  however,  are  still  too  few  to  make 
any  great  impression  on  therapeutic  practice.  In  spite  of  Kalledey's  con- 
tention to  the  contrary,  it  seems  likely  that  the  hemostatic  effect  exhibited 
by  posterior  lobe  extract  in  these  cases  is  due  to  the  resulting  tonic  contrac- 
tion of  the  uterine  muscle,  rather  than  to  any  corrective  endocrinal  effect. 

Organotherapy  of  Functional  Hemorrhages  of  Puberty  and  Menopause. 
Special  consideration  should  be  given  the  type  of  functional  hemorrhage 
which  is  seen  so  characteristically  at  the  two  extremes  of  menstrual  life, 
and  especially  at  the  menopausal  age.  The  general  management  of  these 
cases  has  already  been  outlined  in  Chapter  XXII.  From  the  standpoint  of 
organotherapy,  the  principal  difficulty  is  presented  by  the  fact  that  we  as 
yet  know  little  of  the  endocrinopathy  responsible  for  this  form'  of  menstrual 
disorder.  As  a  matter  of  fact,  it  seems  quite  probable  that  the  nature  of 
the  internal  secretory  disturbance  varies  in  different  cases.  It  is  not  sur- 
prising, therefore,  that  the  results  of  this  plan  of  treatment,  semi-empiric 
as  it  must  be,  have  been  far  from  satisfactory.  The  organ  extracts  which 
deserve  consideration  in  this  connection  are  those  of  the  thyroid,  ovary  and 
pituitary. 

In  the  case  of  the  functional  hemorrhage  of  puberty,  thyroid  extract  has, 
in  my  own  hands,  yielded  the  most  encouraging  results.  To  illustrate,  in  a 
recent  case  of  persistent  and  profuse  bleeding  in  a  girl  of  fourteen,  curettage 
seemed  indicated,  especially  for  diagnostic  purposes.  Microscopic  examina- 
tion of  the  curettings  showed  typical  hyperplasia  of  the  endometrium.  The 
bleeding,  however,  did  not  cease.  The  patient  was  then  given  doses  of 
thyroid  extract  of  two  grains  a  day,  with  almost  immediate  cessation  of  the 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  323 

bleeding.  It  is  only  fair  to  add,  however,  that  similar  medication  in  other 
cases  has  appeared  to  be  of  no  benefit,  indicating,  as  has  already  been 
emphasized,  that  the  endocrine  disorder  is  not  always  of  the  same  character. 

In  the  more  frequent  cases  of  functional  climacteric  hemorrhage,  I  have 
rarely  seen  any  benefit  from  thyroid  medication,  and  not  infrequently  the 
bleeding  has  seemed  to  be  exaggerated.  Somewhat  better  results  have 
followed  the  administration  of  ovarian  extracts,  especially  of  the  corpus 
luteum  preparations.  This  is  in  keeping  with  recent  histological  investiga- 
tons,  which  indicate  that  corpora  lutea  are  commonly  absent  in  cases  of 
hyperplasia  of  the  endometrium  associated  with  uterine  bleeding.  In  other 
words,  even  though  we  are  perhaps  dealing  in  these  cases  with  a  form  of 
ovarian  hypersecretion,  it  is  not  the  corpus  luteum  which  is  overactive. 
Some  other  element  in  the  ovary  is  concerned  with  the  hyperfunction,  the 
corpus  luteum  being  deficient. 

My  most  encouraging  results  have  been  obtained  from  the  exhibition  of 
corpus  luteum  extracts,  either  alone  or  in  combination  with  small  doses  of 
thyroid.  The  corpus  luteum  is  usually  given  in  doses  representing  five  or 
ten  grains  of  the  dried  extract  three  times  a  day.  Or  it  may  be  administered 
subcutaneously  in  the  form  of  the  soluble  extract,  which  is  now  prepared 
commercially  in  convenient  ampoule  form  (i  c.cm.).  One  ampoule  is 
injected  usually  every  second  or  third  day,  depending  on  the  severity  of  the 
hemorrhages.  By  such  measures  the  condition  may  in  some  cases  be  im- 
proved, so  that  the  patient  can  be  tided  over  the  period  of  endocrine  insta- 
bility which  predisposes  to  the  development  of  this  symptom.  As  to  the 
use  of  pituitary  extracts,  little  of  a  definite  nature  can  be  stated.  The  use 
of  posterior  lobe  extracts  has  been  lauded  by  some.  As  I  have  stated  above, 
however,  any  good  results  obtainable  from  these  are  probably  due  to  the 
well  known  effects  of  these  preparations  in  stimulating  contraction  of  the 
uterine  musculature.  The  other  effects  of  these  substances  are  of  such 
potency,  however,  as  to  contraindicate  their  continued  administration  for  a 
prolonged  period.  Anterior  lobe  extracts  have  achieved  no  important  place 
in  the  treatment  of  these  troublesome  cases,  and,  indeed,  there  would  seem 
to  be  no  especial  rationale  for  their  employment. 

It  is  unfortunate  that  we  cannot  be  more  explicit  in  suggestions  as  to 
the  organotherapy  of  this  exceedingly  important  type  of  hemorrhage,  and 
that  our  efforts  to  attack  it  along  what  seem  to  be  rational  lines  have  not 
met  with  a  greater  measure  of  success,  but  I  believe  that  what  has  been  said 
above  represents  the  worth  while  in  our  present  knowledge  of  the  subject. 

Vasomotor  Symptoms  of  Menopause. —  The  principal  field  of  useful^ 
ness  of  ovarian  or  corpus  luteum  preparations  is  in  the  treatment  of  the 
troublesome  subjective  symptoms  so  often  observed  at  the  menopause,  and 
especially  those  due  to  vasomotor  disturbance  of  one  form  or  another.  Under 
this  head  are  to  be  placed  the  hot  flushes  and  the  "  flashes  "  of  heat,  which 
constitute  the  most  characteristic  and  at  the  same  time  the  most  troublesome 
symptoms  of  the  climacterium,  whether  natural  or  artificial.     Drugs  are  of 


324  MENSTRUATION  AND  ITS  DISORDERS 

little  service  in  the  relief  of  this  group  of  symptoms.  It  is  here  that  the 
organ  extracts  have  one  of  their  most  important  gynecological  applications. 
Burnam  states  that  corpus  luteum  extracts  yield  great  Improvement  in 
menopausal  symptoms  in  90  per  cent  of  cases,  and  I  do  not  believe  that  this 
is  an  overstatement.  As  has  been  indicated  in  a  preceding  paragraph,  my 
own  preference  in  the  treatment  of  this  group  of  cases  is  for  corpus  luteum 
preparations  rather  than  those  made  from  the  entire  ovarian  substance.  It 
is  only  fair  to  say,  however,  that  many  gynecologists  report  results  from 
extract  of  whole  ovary  which  are,  to  say  the  least,  equally  as  good  as  those 
observed  from  the  administration  of  corpus  luteum  preparations. 

In  view  of  the  rather  large  number  of  commercial  preparations  of  both 
ovarian  and  corpus  luteum  extracts,  it  is  scarcely  possible,  in  this  discus- 
sion, to  suggest  definite  dosages.  Speaking  generally,  it  may  be  said  that 
the  average  dose  of  corpus  luteum  extract  advisable  in  the  treatment  of 
menopausal  symptoms  is  about  five  grains,  three  times  a  day,  of  the  dried 
substance.  There  are  some  who  recommend  much  larger  doses  than  this 
(Hill,  Burnam),  but  I  have  personally  seldom  seen  good  results  from  very 
large  doses  when  smaller  ones  had  failed  to  improve  the  patient's  condition. 
A  great  comfort  in  this  form  of  treatment  is  the  fact  that  the  extract  is, 
within  ordinary  limits,  nontoxic,  and  hence  can  work  no  harm  to  the 
patient.  Occasionally,  however,  prolonged  corpus  luteum  medication  with 
even  very  moderate  doses  may  cause  more  or  less  gastric  irritation. 

Dysmenorrhea. —  Since  this  chapter  aims  only  to  sketch  the  more  im- 
portant indications  for  organotherapy  in  menstrual  disorders,  we  need  make 
only  a  passing  reference  to  the  fact  that  some  have  used  ovarian  substances 
in  the  treatment  of  primary  dysmenorrhea.  This  practice  is  obviously 
based  on  the  doubtful  theory  that  the  underlying  cause  of  this  symptom  is 
a  hypogenitalism.  At  any  rate,  the  results,  so  far  as  I  have  been  able  to 
learn,  have  been  of  no  particular  value.  If  ovarian  extract  is  to  be  employed 
in  cases  of  apparent  underdevelopment  of  the  generative  apparatus,  the 
extract  made  from  the  entire  ovary  would  seem  preferable  to  that  made  from 
the  corpus  luteum  alone,  for  reasons  which  have  already  been  indicated. 

There  are  good  grounds  for  believing  that  primary  dysmenorrhea  is  due 
to  a  hypopituitarism  rather  than  to  a  hypogonadism  (see  Chapter  XX). 
Certainly  this  statement  would  seem  to  be  correct,  as  applied  to  the  uterine 
hypoplasia  which  is  seen  so  characteristically  in  patients  suffering  from  this 
form  of  menstrual  pain.  The  administration  of  pituitary  extracts  in  these 
cases  would  appear  to  be  a  rational  procedure,  the  preference  being  for 
anterior  lobe  extracts,  or  perhaps  better,  for  the  whole  gland  substance. 
This,  according  to  Gotsch,  should  be  given  in  initial  doses  representing  five 
grains  of  the  dried  gland  three  times  a  day,  increasing  the  dose  gradually, 
if  necessary. 


THE  ORGANOTHERAPY  OF  MENSTRUAL  DISORDERS  325 

XXVI 
LITERATURE 

Bab.     Pituitrin  als  Gynakologischen  Styptikum.    Miinch.  Med.  Wchnsch.,  191 1, 

58.  1554- 
Beck.     Hypophyseal  Disorders,  with  Special  Reference  to  Frolich's  Syndroms 

Endocrinology,  1920,  4,  185. 
Bernard.     Legons  de  physiologic  experimentale,  1855. 
BiEDL.     Innere  Sekretion.     Berlin,  1910. 
Block  and  Llewellyn.     Organotherapy   in   Gynecology.     Amer.   J.   Obst., 

1917,  75,  357- 
Brown-Sequard.     Des  effets  produits  chez  1'  homme  par  des  injections  sous- 
contanees  d'  un  liquide  retire  des  testicules,  etc.     Compt.  Rend.  Soc.  de 
Biol.,  1889,  41,  415. 

Experience  demonstrant  la  puissance  dynamogenique  chez  Thomme  d'un 

liquide  extrait  des  testicules  animaux.     Arch,  de  Phys.  Norm,  et  Path., 
1889,  I,  651. 

BuRNAM.     Corpus  Luteum  Extract.     Jour.  A.  M.  A.,  1912,  59,  698. 
Dannreuther.     Corpus  Luteum  Therapy  in  Clinical  Practice.     Jour.  A.  M. 

A.,  1914,  62,  359. 
EscH.     Die   Organextrakttherapie  bei   Menstruationsstorungen.     Zentralb.    f. 

Gyn.,  1920,  44,  561. 
Fraenkel.     Die  Funktion  des  Corpus  Luteum.     Arch.  f.  Gyn.,  1903,  68,  438. 
Fries.     Behandlung  der  Amenorrhoe.    Deutsch.  Med.  Wchnsch.,  1913,  39,  675. 
From  ME.     Zur  Behandlung   der  Amenorrhoe.     Zentralb.   f.   Gyn.,    1912,   36, 

1366. 
Gonalons.     Experimental  Physiological  Action  of  Ovarian  Extracts.     Surg. 

Gyn.,  and  Obst,  1918,  26,  196. 
Graves.     Ovarian  Organotherapy.     Jour.  A.  M.  A.,  191 7,  69,  701. 
Jaeger.     Value  of  the  Extract  Corpora  Lutea.     Ther.  Gaz.,  1912,  36,  461. 
Jona.     Menopausa  precoce ;    sindrome  ipofisaria ;    opoterapia.     Gazett.   degli 

Ospedal.,  1916,  1J,  420. 
Happel.     Therapeutic  Use  of  Corpus  Luteum  Extract.     Med.  Rec,  1917,  91, 

848. 
Henkel.     Ueber   die   Wechselbeziehung   zwischen   Uterus  und   Ovarien,   ein 

Beitrag  zur   Behandlung   Gynakologischen   Blutungen.     Miinch.    Med. 

Wchnsch.,  191 1,  58,  336. 
Hill.     Corpus  Luteum  in  the   Treatment  of  Artificial   Menopause.     Surg., 

Gyn.,  and  Obst,  1910,  11,  589. 
Hirst.     Corpus  Luteum  Extract  in  Nausea  of  Pregnancy.     Jour.  A.  M.  A., 

1916,  66,  645. 

Control  of  Disagreeable  Symptoms  of  Surgical  Menopause  by  Hypo- 
dermic Intramuscular  Administration  of  Corpus  Luteum  Extract.  Am. 
J.  Obst.,  1916,  73,  648. 

Hofstatter.     Zur  Behandlung  der  Amenorrhoe.     Zentralb.  f.  Gyn.,  1912,  36, 

1536. 

Ueber  die  Verwendung  von  Hypophysen  substanzen  bei  der  Behandlung 

der  Amenorrhoe.     Zentralb.  f.  Gyn.,  1920,  44.  57. 


326  MENSTRUATION  AND  ITS  DISORDERS 

Kalledey.  Zur  Lehre  von  der  Atiologie  und  Organotherapie  der  Uterus- 
blu'tungen.     Gynak.  Rundschau,  191 3,  7,  473. 

Klein.  Adrenalin  und  Pituitrin  bei  Dysmenorrhoe.  Monats.  f.  Geb.  u. 
Gynak.,  1913,  37,  169. 

Kohler.  Beitrag  zur  Organotherapie  der  Amenorrhoe.  Zentralb.  f.  Gyn.. 
1915*  39,  667. 

KosMiNSKi.  Zur  Behandlung  der  Amenorrhoe  mit  Hypophysenextrakten 
Deut.  Med.  Wchnsch.,  1913,  40,  1655. 

Landau.  Zur  Behandlung  von  Beschwerden  der  Natiirlichen  und  Anticipirten 
KHmax  mit  Eierstockssubstanz.     Berl.  Klin.  Wochensch.,  1896,  33,  557. 

Leighton.  The  Use  of  Corpus  Luteum  Extract  in  the  Treatment  of  Menstrual 
Disorders.     Am.  J.  Obst,  1915,  72,  878. 

Mainzer.  Vorschlag  zur  Behandlung  der  Ausfallserscheinungen  nach  Castra- 
tion.    Deutsch.  Med.  Wchnsch.,  1896,  22,  188. 

McDonald.  Lutein  Extract  in  the  Treatment  of  Decreased  Menstruation  and 
Premature  Menopause.     Jour.  A.  M.  A.,  1910,  55,  205. 

Mekerttschiantz.  tJber  die  Anwendung  von  Ovarinum-Poehl  bei  Amenor- 
rhoe.   Gyn.  Rundsch.,  1910,  4,  256. 

MoRLEY.     Ovarian  Extract.     J.  Mich.  State  Med.  Asso.,  1916,  15,  372. 

Novak.     Organotherapy  of  Menstrual  Disorders.     Med.  and  Surg.,  191 7,  i, 

576. 
Offergeld.     Klinische      Versuche     mit     Ovarialsubstanz,     Deutsch.      Med. 

Wchnsch.,  191 1,  Z7y  1172. 
Roblee.     Report  of   Case   of   Dystrophia  Adiposogenitalis.     Endocrinology, 

1917,  I,  286. 
RoYSTON.     Dysmenorrhea.     J.  Missouri  M.  Asso.,  1916,  13,  495, 
Sajous.     The  Corpus  Luteum  in  Therapeutics.     N.  Y.  Med.  J.,  1916,  103,  227. 
Seitz^  Wintz^  und  Fingerhut.     Ueber  die  Biologische  Funktion  des  Corpus 

Luteum,  seine  Chemische  Bestandteilc  und  deren  Therapeutische  Ver- 

wendung  bei   Unregelmassigkeiten   der   Menstruation.      Miinch.    Med. 

Wchnsch.,  1914,  61,  1657. 
Teleky,     Die  Organotherapie  in  der  Gynakologie.     Wien.  Med.  Wchnsch., 

1912,62,2953 
Watson.     Organotherapy  in  Gynecology  and  Obstetrics.     Canad.  M.  Ass.  J., 

1915,  5.  667. 
Zoppritz.     Die  Behandlung  der  Amenorrhoe.     Miinch.  Med.  Wchnsch.,  1913, 
60,  1456. 


CHAPTER    XXVII 

THE  TREATMENT  OF  MENSTRUAL  DISORDERS  BY  RADIUM  AND  X-RAY 
By  Howard  A.  Kelly,  M.  D.,  and  Curtis  F.  Burnam,  M.  D, 

Introduction. —  The  microscopic  changes  in  tissues  subjected  to 
radium  or  X-ray  radiation  are  very  similar  and  the  general  physiological 
effects  induced  in  an  individual  women  through  X-ray  or  radium  steriliza- 
tion are  so  nearly  the  same,  that  it  seems  logical  as  well  as  convenient  to 
consider  these  two  therapeutic  agents  together. 

It  should  not  be  assumed,  however,  that  they  are  necessarily  exactly 
equivalent  and  that  they  can,  in  every  instance,  be  used  interchangeably;  for 
it  is  certain  that  many  cases  are  much  more  easily  and  effectively  treated 
with  intra-uterine  radium  than  by  any  transabdominal  method.  This  differ- 
ence is  striking  when  a  rapid  and  complete  amenorrhea  is  sought.  When  a 
considerable  amount  of  radium  is  available  for  transabdominal  radiation,  the 
operator  can  secure  more  easily  the  desired  changes  in  the  ovaries  and 
uterus  than  by  X-ray  methods,  and  certainly  with  less  risk  to  the  skin  and 
underlying  integument.  It  is  only  fair  to  state,  however,  that  the  authors 
have  been  much  more  concerned  with  the  development  and  employment  of 
radium  than  X-ray  technics. 

History. —  William  James  Morton,  the  first  to  demonstrate  that 
uterine  hemorrhage  due  to  myomata  could  be  helped  by  X-raying  the  tumor 
through  the  lower  abdomen,  reported  his  cases  in  the  New  York  Medical 
Record  of  the  issue  of  July  25,  1903.  It  was  more  than  three  years  later 
when  radium  in  the  uterus  was  first  used  for  the  same  purpose  by  Oudin 
and  Verchere,  two  French  observers  who  reported  their  experiences  in  the 
Ann.  d'Electrol.,  Oct.  31,  1906.  Oudin  also  published  a  report  in  the  same 
journal  in  August,  1907. 

In  addition  to  the  customary  inertia  which  must  be  overcome  to  intro- 
duce any  new  method  of  doing  things,  three  definite  factors  militated 
against  the  wide  acceptance  and  employment  of  these  agents.  There  was, 
first  of  all,  a  successful,  well  developed  and  widely  applied  surgical  treat- 
ment which  had  been  won  only  after  the  great  labor  and  toil  of  more  than 
a  decade ;  secondly,  the  ray  treatment  was  uncertain  and  on  account  of  its 
duration  —  often  months  —  was  very  trying  to  the  patience  of  both  the  phy- 
sician and  the  patient;  thirdly,  and  finally,  in  not  a  few  cases  painful  and 
dangerous  skin  burns  followed  the  treatment. 

It  is  not  surprising,  therefore,  that,  in  spite  of  the  good  results  obtained 

327 


328  MENSTRUATION  AND  ITS  DISORDERS 

by  the  occasional  and  desultory  use  of  X-ray  by  rontgenologists,  the 
method  had  no  wide  acceptance  and  did  not  take  its  place  in  the  gyne- 
cological armamentarium  until  after  Professors  Kronig  and  Gauss  of  Frei- 
burg had  developed  a  technic  which  was  curative  in  a  few  months  from  the 
beginning  of  treatment,  which  did  not  burn  or  injure  the  patient,  and  which 
proved  so  uniformly  successful  through  a  long  series  of  cases  treated  at  the 
Freiburg  University  gynecological  clinic.  The  publication  of  their  studies 
and  the  conclusion  drawn  that  a  safer  and  more  efficient  way  of  treating 
uterine  fibroids  was  by  X-ray  rather  than  by  surgical  procedures,  met  with 
almost  universal  condemnation  by  the  German  gynecologists.  Neverthe- 
less, in  less  than  two  years  from  1912,  the  date  of  the  principal  publications 
from  Freiburg,  every  gynecological  clinic  in  Germany  was  busily  engaged 
in  running  its  X-ray  machine  from  morning  till  night,  and  it  was  generally 
acknowledged  that  the  new  procedure  was  very  valuable. 

In  this  country  as  well  as  in  Great  Britain  there  has  been  nothing  like 
such  an  acceptance  or  trial  of  either  X-ray  or  radium  by  gynecologists.  In 
France,  where  some  of  the  very  earliest  and  best  work  in  this  field  was 
done.  X-ray  and  radium  are  widely  employed. 

Radium  has  nowhere  been  so  extensively  used  as  the  X-ray,  due  in  part 
perhaps  to  its  cost  and  the  difficulty  in  procuring  it.  It  is,  however,  now 
being  employed  at  many  of  the  gynecological  clinics  in  America,  and  is  very 
favorably  regarded  by  those  who  have  had  experience  with  it.  John  G. 
Clark  of  Philadelphia,  C.  Jeff  Miller  of  New  Orleans,  Henry  Schmitz  of 
Chicago,  and  many  others  have  published  most  satisfactory  experiences. 
It  was,  perhaps,  chiefly  due  to  the  work  of  Cheron,  which  began  in  1909, 
his  first  publication  being  in  191 1  (Cheron,  Arch,  d'Electr.  Med.,  Bordeaux, 
191 1,  xix,  355),  and  to  our  own  work  which  began  in  191 1  and  which  was 
first  made  public  at  the  1914  meeting  of  the  American  Medical  Association, 
and  published  in  the  same  year  (Kelly  and  Burnam,  Jour.  Am.  Med.  Ass., 
1914,  Ixiii,  622),  that  there  originated  an  impulse  which  has  led  tO'  the 
enthusiastic  and  valuable  work  of  sO'  many  physicians  in  this  field. 

Literature. —  The  most  convenient  source  of  literature,  to  those 
readers  especially  interested  in  the  original  publications,  is  to  be  found  in 
the  volumes  of  Strahlentherapie. 

Most  of  these  studies  deal  with  the  effects  of  ray  therapy  on  uterine 
hemorrhage  and  fibroids.  There  is  but  scant  mention  of  the  pain  feature 
of  dysmenorrhea  and,  while  in  a  number  of  reports  there  may  be  a  para- 
graph or  so  dealing  with  the  character,  severity  and  frequency  of  meno- 
pausal symptoms  sequent  to  the  ray  menopause,  these  are  nowhere  taken  up 
as  the  prime  object  of  study.  So  far  as  we  are  aware,  there  is  no  existing 
publication  dealing  with  the  ray  treatment  of  nervous  disorders  associated 
with  or  in  any  way  dependant  on  the  periodic  menstrual  disturbance. 

The  available  literature  dealing  with  the  treatment  of  dysmenorrhea  not 
associated  with  menorrhagia  is  limited  to  the  X-ray.  Doderlein  (Doderlein, 
Monatschr.   f.   Geburtshiilfe  u.   Gynak.,  xxxiii,   Hft.   iv,  413)    states  that 


TREATMENT  OF  MENSTRUAL  DISORDERS   BY  RADIUM  AND  X-RAY    329 

the  dysmenorrhea  of  young  patients  is  favorably  influenced  by  X-ray  treat- 
ment. Eymer  and  Menge  (Eymer  u.  Menge,  Monatschr.  f.  Geburtshiilfe 
u.  Gyniik.,  xxxv,  Hft.  3,  268)  saw  benefit  for  one  period  in  two  cases. 
Frankel  (Frankel,  Bed.  Khn.  Wchnschr.,  Nr.  34,  16 10)  holds  that  ovarian 
dysmenorrhea,  but  not  uterine,  can  be  benefited.  Reififerscheid  (Reiffer- 
scheid,  Strahlentherapie,  vol.  iv,  19 14,  p.  146)  in  a  series  of  five  cases  had 
one  marked  improvement,  two  temporary  improvements,  and  one  slight 
improvement.  Such  is  the  scant  literature  we  have  found  dealing  with  this 
important  subject. 

Anatomical  Changes  Observed  in  the  Ovaries  and  in  the  Uterus 
After  Radiation. —  Practically  all  the  histo-anatomical  investigations 
that  have  been  published  are  limited  to  a  study  of  the  effect  of  radiation  on 
the  ovaries,  and  this  doubtless  explains  why  it  was  held  for  so  long  that  the 
ray  efifect  on  uterine  fibroids  and  hemorrhage  was  entirely  an  indirect  one 
through  the  ovaries.     We  know  now  that  this  is  only  partially  true. 

As  early  as  1903,  it  was  already  recognized  that  marked  degenerative 
changes  were  induced  by  intense  radiation  of  either  the  male  or  female 
generative  organs,  and  that  consequent  sterility  followed.  Splendid  studies 
are  those  of  Reifferscheid  (Reifferscheid,  Strahlentherapie,  191 5,  vol.  v, 
p.  407)  and  CI.  Regaud  and  Lacassagne  (CI.  Regaud  et  Lacassagne,  Jour, 
de  Physiotherap.,  Oct.  1913,  546,  550).  The  most  vulnerable  part  of  the 
ovary  is  the  graafian  follicle,  the  ovum  and  granulosa  layer  being  the  first 
to  show  disintegration.  The  germinal  epithelium  and  the  corpus  luteum 
are  much  more  resistant.  In  some  experiments  with  animals  marked 
changes  have  been  shown  within  twenty-four  hours,  but  the  summit  of 
change  after  a  single  treatment  may  not  be  reached  for  six  weeks.  The 
primordial  follicles  stand  intermediary  in  vulnerability  between  the  graafian 
follicles  and  the  corpus  luteum  tissue.  Under  very  heavy  radiation  they 
too  may  be  completely  destroyed.  As  a  rule,  however,  only  a  part  of  them 
are  destroyed  and  the  others  are  subjected  in  their  ripening  to  a  period  of 
inhibition,  varying  from  one  to  several  months  in  animals,  while  in  human 
beings,  according  to  our  clinical  experiences,  it  is  common  for  this  period  to 
extend  over  from  one  to  three  years. 

The  anatomical  changes  in  the  uterus  dependant  on  radiation  are  much 
more  difficult  to  interpret  and  much  less  characteristic  than  those  observed 
in  the  ovaries.  When  permanent  amenorrhea  is  induced,  the  entire  uterus, 
corpus  and  cervix,  shrink  markedly  in  volume.  This  decrease  in  size  is 
associated  with  relatively  marked  diminution  in  the  musculature,  with 
endarteritic  changes  in  the  blood  vessels,  and  with  a  decided  thinning  of 
the  glandular  part  of  the  endometrium.  Where  there  has  been  an  intrac- 
table tendency  to  the  formation  of  a  polypoid  endometrium,  a  single  intra- 
uterine treatment  of  mild  intensity  may  cause  it  to  disappear  permanently. 
This  is  well  established  in  several  cases  under  personal  observation. 

In  certain  uterine  fibroids  removed  by  operation  after  radiation,  there 
has  been  observed  the  destruction  of  cell  nuclei  and  the  running  of  the 


330  MENSTRUATION  AND  ITS  DISORDERS 

chromatin  into  large  lakes,  a  change  characteristic  of  ray  destruction  of 
many  malignant  tissues.  From  these  changes,  in  general  corresponding  to 
those  familiar  in  the  senile  uterus,  observed  in  some  cases,  there  is  a  gradual 
lessening  until  no  alteration  whatever  can  be  definitely  described. 

The  Ray  Menopause. —  In  our  very  first  observations,  the  almost 
complete  absence  of  hot  flushings,  sweatings,  and  the  nervous  manifesta- 
tions which  we  had  grown  to  expect  with  oophorectomy  amenorrhea,  aston- 
ished us.  A  consideration  of  the  anatomical  changes  already  described 
makes  this  easily  understandable  — ■  the  existing  corpora  lutea  persist  for 
several  months,  the  primordial  follicles,  or  some  of  them,  indefinitely. 
Nevertheless,  a  considerable  number  of  radium  amenorrheas  are  associated 
with  distinctive  menopausal  disturbances. 

In  a  continuous  series  of  no  cases,  50  per  cent  made  no  complaint,  about 
25  per  cent  made  slight  complaint  and  almost  25  per  cent  complained  of 
pronounced  flushings.  Not  one  patient  considered  the  hot  flushings  or 
nervous  disturbances  disagreeable  enough  to  make  her  regret  the  treatment. 
The  usual  expression  has  been  that  the  general  improvement  in  health  and 
well  being  has  been  pronounced. 

It  should  be  of  some  weight  in  this  connection  to  state  that  the  general 
psychic  atmosphere  in  many  of  these  patients  has  not  been  of  the  best. 
Well  meaning  friends  have  suggested  premature  aging,  loss  of  mind,  etc.,  as 
a  consequence  of  the  treatment. 

We  have  had  some  experience  with  patients  predisposed  or  actually 
psychically  disturbed  and  have  noticed  no  tendency  in  the  treatment  to 
precipitate  attacks  of  mental  upset.  However,  it  is  possible  that  this  might 
follow  in  some  cases,  and  the  matter  cannot  be  definitely  adjudged  except 
after  prolonged  investigation. 

The  Technic  of  Radiation. —  The  reader  is  referred  to  the  original 
literature  appended  for  his  convenience  at  the  end  of  this  chapter,  and  is 
advised  to  see  personally  the  actual  carrying  out  of  X-ray  and  radium  treat- 
ments in  the  hands  of  those  familiar  with  them,  before  personally  under- 
taking either. 

The  X-ray  technic  of  Gauss  and  Lembcke  consists  in  the  individual  m^ax- 
imum  dosage  of  the  pelvic  organs  at  intervals  of  from  four  to  eight  weeks 
until  the  desired  result  is  obtained.  With  the  X-ray  tube  at  a  focal  distance 
of  15  cm.  and  the  rays  filtered  through  at  least  3  mm.  of  aluminum,  the 
treatment  is  given  through  a  number  of  portals  on  the  skin  of  the  lower 
abdomen  and  back.  The  use  of  many  portals  secures  adequate  inside  dosage 
without  endangering  the  skin  at  any  one  point.  The  replacement  of  the 
old  water  cooled  air  tubes  by  the  now  universally  used  Coolidge  tube  has 
made  the  treatment  more  economical  and  has  greatly  simplified  the  accurate 
measurement  of  the  dosage  given. 

When  radium  is  used  from  the  abdomen,  two  or  three  portals  are  advis- 
able at  a  distance  of  from  5  to  15  cm.  from  the  skin.  The  filtration  should 
be  through  3  mm.  of  lead.     Comparatively  large  quantities  of  radium  are 


TREATMENT  OF  MENSTRUAL  DISORDERS   BY   RADIUM   AND  X-RAY     331 

desirable,  if  not  absolutely  necessary.  The  average  dose  where  a  complete 
amenorrhea  is  desired  is  24,000  mg.  hours.  Treatment  should  not  be 
repeated  within  four  weeks. 

In  intra-uterine  radiation,  the  radium  in  a  convenient  applicator  is  so 
placed  or  moved  that  the  entire  surface  of  the  uterus  gets  an  equal  treat- 
ment, amounting  on  the  average  to  about  1,500  mg.  hours. 

There  is  a  wide  variation  in  the  dosage  necessary  to  bring  about 
amenorrhea.  If  it  is  desirable  to  do  so,  however,  it  is  always  possible  to 
produce  it  at  a  single  treatment  by  a  combination  of  inside  and  outside 
radiation.  Overradiation  inside  may  produce  discharges  and  pain  for 
weeks,  but  it  is  never  necessary  to  cause  these  symptoms.  But  little  differ- 
ence has  been  noted  in  young  subjects  and  those  over  forty  in  their  response 
to  inside  radiation,  although  there  is  quite  marked  difference  when  the 
treatments  are  given  transabdominally ;  and  by  X-ray  it  is  sometimes  impos- 
sible to  attain  a  complete  result  in  young  patients. 

Classification  of  Dysmenorrhea  from  the  Ray  Therapy  Standpoint. — 
While  no  sharp  separation  of  the  various  disturbances  of  menstruation 
occurs  in  practice,  the  same  patient  frequently  having  hemorrhage  and  pain 
as  well  as  nervous  and  general  upset,  nevertheless,  for  convenience  in  expo- 
sition, it  is  clearer  to  consider  the  effects  on  each  of  these  phases  of 
dysmenorrhea  separately  and  individually.  As  a  matter  of  fact,  one  or  the 
other  is  apt  to  dominate  the  clinical  picture  and  is  essentially  the  real  reason 
for  the  institution  of  treatment. 

Cases  with  Abnormality  of  the  Menstrual  Flow. —  Patients  with  ab- 
normality of  the  menstrual  flow  should  be  divided  into  those  who  are 
suffering  from  anemia  through  pronounced  loss  of  blood  and  those  who 
are  merely  inconvenienced  by  prolonged  or  continuous  bleeding.  It  need 
be  recalled  here  that  the  hematopoietic  system  varies  immensely  and  that  one 
individual  is  not  discommoded  by  an  amount  of  blood  loss  that  is  dangerous 
to  another  person. 

After  having  determined  on  ray  therapy,  the  operator  may  choose  any 
one  of  three  ends.  The  treatment  may  aim  at  simple  reduction  of  the 
intensity  or  duration  of  the  flow,  or  it  may  aim  to  bring  about  an  amenorrhea 
for  a  time,  with  the  hope  that  during  this  period  the  patient  will  recover  her 
health  and  that  when  the  periods  return  they  will  be  so  modified  as  to  cause 
no  trouble,  or  the  aim  from  the  very  beginning  may  be  to  produce  permanent 
amenorrhea  and  sterility.  These  different  aims  can  be  met  by  employing 
different  intensities  of  radiation.  In  the  first  group  comparatively  mild 
treatments,  in  the  third  group  very  heavy  treatments  must  be  employed. 

Whether  a  complete  amenorrhea  is  desirable  in  any  individual  case 
depends  a  great  deal  on  the  age  of  the  patient  and  on  her  social  surround- 
ings and  conditions.  Unless  there  is  a  very  good  reason  for  making  it 
permanent,  it  is  a  good  working  plan  to  produce  by  the  first  treatment  a 
temporary  amenorrhea,  and  to  wait  and  see  if  this  does  not  fulfil  all  the 
desirable  objects  of  the  treatment.     If,  on  the  return  of  bleeding,  it  is  still 


332  MENSTRUATION  AND  ITS  DISORDERS 

excessive,  then  another  treatment  can  be  carried  out  and  the  result  made 
permanent.  Before  radiating  a  girl  or  young  woman  for  excessive  flow, 
it  is  imperative  to  try  out  thoroughly  the  simpler  plans  of  treatment  — 
medicinal,  hygienic  and  curettage. 

All  but  the  most  obstinate  cases  may  thus  be  excluded  from  a  treatment 
which  might  readily  cause  sterility.  That  this  may  be  more  of  a  theoretical 
than  an  actual  danger  is  evidenced  by  two  of  our  patients,  who,  after  pro- 
longed amenorrhea,  had  a  return  of  menstruation,  married,  and  each  had  a 
perfectly  normal  child.  In  older  women  it  is  less  important  to  consider 
this  phase  of  the  problem  and  in  those  near  the  menopause  a  permanent 
amenorrhea  should  be  aimed  at.  In  most  cases  where  amenorrhea  of  sev- 
eral months  has  been  obtained,  the  return  of  menstruation  has  been  marked 
by  a  normal  flow.  In  a  series  of  164  cases  of  bleeding  fibroids  or  simple 
bleeding  uterus  there  has  been  no  death  and  no  serious  consequence  of  any 
kind  following  the  treatment,  and  the  results  in  relief  of  the  bleeding  have 
been  most  satisfactory. 

Finally,  in  patients  who  are  not  anemic  and  who  are  willing  to  wait  for 
results,  very  mild  treatments  to  control  but  not  stop  menstruation  will,  in  a 
considerable  proportion  of  cases  treated,  give  satisfactory  results  in  both 
reducing  the  flow  and  in  lessening  discomfort.  A  very  mild  intra-uterine 
application  may  be  effectual  in  curing  a  tendency  to  bleed  almost  continu- 
ously but  never  excessively.  We  have  seen  one  such  patient  who  had  lost 
all  count  of  her  periods  and  who  had  resisted  curettages  and  various  appli- 
cations and  who  has,  after  a  single  treatment,  been  perfectly  regular  for 
several  years. 

Cases  Characterized  by  Painful  Menstruation. —  That  ray  therapy 
should  be  considered  in  these  conditions  is  made  obvious  by  recalling  that 
menstruation  can  be  permanently  done  away  with  through  its  adequate  use. 
It  is  equally  obvious,  however,  that  it  should  be  used  only  in  the  very 
exceptional  case  in  young  women,  who  constitute  the  large  majority  of 
such  patients.  In  older  women  the  development  of  painful  menstruation 
usually  is  associated  with  the  appearance  of  a  fibroid  tumor  or  some  tubo- 
ovarian  complication,  especially  chronic  pelvic  inflammatory  disease.  The 
value  of  the  treatment  in  uterine  fibroids  has  been  shown  in  many  cases. 
Our  experience  with  the  chronic  pelvic  inflammatory  group,  as  yet  quite 
limited,  is,  however,  most  encouraging,  and  it  is  our  opinion,  on  the  basis 
of  only  six  cases,  all  quite  satisfactorily  treated,  that  ray  therapy  will  ulti- 
mately find  here  a  very  satisfactory  and  large  field  of  usefulness.  Many  of 
the  chronic  pelvic  inflammatory  sufferers  are  principally  upset  only  during 
the  period  of  menstrual  congestion.  These  patients  should  preferably  be 
treated  by  the  transabdominal  route. 

Radiation  which  aims  to  reduce  but  not  stop  menstruation  would  seem 
to  be  the  method  of  ray  treatment  best  applicable  to  the  painful  dysmenor- 
rhea unassociated  with  organic  disease  of  the  uterus,  tubes  or  ovaries,  and 
which  is  commonest  in  young  and  unmarried  women.     Unfortunately  the 


TREATMENT  OF  MENSTRUAL  DISORDERS  BY  RADIUM  AND  X-RAY    333 

relief  obtained  is  usually  temporary  and  partial.  In  a  scries  of  nine  cases 
we  have  had  one  complete  success  of  i8  months  standing,  two  partial 
successes  and  six  failures. 

Cases  with  Marked  Nervous  or  Psychical  Disturbances  Present 
Principally  or  Solely  During  the  Menstrual  Periods. —  There  are  but 
few  medical  men  who  have  not  had  experience  with  patients  who  are  enor- 
mously upset  during  the  menstrual  period.  Some  of  them  are  sick  half  or 
more  of  the  time.  We  need  not  repeat  here  the  protean  symptomatology 
of  headaches,  nausea,  anorexia,  mental  depression,  etc.  These  patients  are 
most  frequently  encountered  during  the  early  and  late  years  of  menstrual 
life.  The  clinical  picture  suggests  autointoxication.  While,  as  already 
stated  on  page  330,  the  induced  ray  menopause  has  not  made  patients  more 
uncomfortable  from  the  ner^'ous  and  general  functional  standpoints,  it  has 
not  been  emphasized  enough  that  very  many  of  them  report  great  improve- 
ment in  these  directions.  This  conforms  with  the  nervous  improvement 
frequently  observed  at  the  time  of  the  normal  menopause. 

It  must  be  constantly  kept  in  mind,  however,  that  many  functional  and 
nervous  disturbances  due  to  a  great  variety  of  organic  conditions  totally 
unconnected  with  the  pelvic  organs  may  be  greatly  exaggerated  at  the 
menstrual  period,  and  as  a  consequence  may  closely  simulate  the  menstrual 
intoxications.  A  most  careful  general,  physical  and  psychic  examination 
should  be  made  of  these  patients  before  giving  ray  therapy  to  induce  a 
menopause. 

We  have  successfully  treated  nine  such  cases,  three  of  whom  felt  perfectly 
well  except  at  the  period  time.  Two  of  the  three  had  headaches,  nausea, 
extreme  general  nervousness  and  weakness,  and  the  third  fearful  mental 
depression.  All  have  been  perfectly  well  after  the  establishment  of  a  com- 
plete amenorrhea.  In  two  other  cases  almost  equally  satisfactory  results 
have  been  obtained,  although  the  nervousness  in  these  was  present  during 
the  entire  month,  and  was  merely  greatly  exaggerated  at  the  menstrual 
periods. 

In  four  cases  the  results  \vere  unsatisfactory.  One  of  these  was  a  suf- 
ferer from  hyperthyroidism ;  another  had  marked  religious  delusions  present 
all  the  time,  but  exaggerated  during  the  period ;  a  third  was  a  typical  hypo- 
chondriac neurasthenic ;  and  the  fourth  a  patient  insufficiently  treated  and 
still  menstruating. 

Another  interesting  group  has  been  that  of  four  patients  treated  for 
epilepsy.  In  one  of  these,  a  woman  of  44  years,  there  have  been  no  attacks 
in  four  and  a  half  years  since  her  treatments.  In  the  other  three  there 
was  a  distinct  and  marked  improvement.  All  tended  to  have  the  attacks 
principally  at  the  time  of  the  periods. 


334  MENSTRUATION  AND  ITS  DISORDERS 

XXVII 
LITERATURE  (ADDITIONAL) 

Chase.     Radium  Treatment  of  Uterine  Hemorrhage.     Amer.  J.  Obst,  191 7, 

75.  500. 
FoGES.     Ueber  Rdntgentherapie  bei  Uterusblutungen.     Wien.  Med.  Wchnsch., 

1913,  63,  995. 
Frank.     The  Use  of  X-ray  in  Uterine  Hemorrhage.     Amer.  J.  Obst.,  1916," 

74,  321.  _ 

FucHS.     Rontgentherapie  odor  Vaporisation  bei  Hamorrhagischen  Metropa- 

thien.     Monats.  f.  Geb.  u.  Gyn.,  1913,  37,  496. 
Gauss  und  Lembcke.     Rontgentherapie,  Urban  u.   Scharzenberg,  Bedir  u. 

Wien,  1912. 
Grafenberg.     Die   Rontgenstrahlung  in  der  Myombehandlung.      Zeitsch,   f. 

Geburts.  il  Gynak.,  1912,  "jo.,  215. 
Keene.     Radium  in  Gynecology.     Penn  M.  J.,  1917,  20,  469. 
Kelly  and  Burnam.     Radium  in  Treatment  of  Uterine  Hemorrhage  and 

Fibroid  Tumors.     Jour.  Amer.  Med,  Asso.,  1914,  63,  622. 
Kr5nig.     Die    Rontgentherapie    in    ihrer    Bedeuitung    fur    die    Gynakologie. 

Strahlentherapie,  191 2,  i,  6. 
Lange.     a  PreHminary  Report  of  the  X-ray  Treatment  of  Menorrhagia  and 

Uterine  Fibroids.     Lancet-CHnic,  Cinn.,  1915,  114,  59. 

' Recent  Results  in  X-ray  Treatment  of  Menorrhagia,  Dysmenorrhea  and 

Uterine  Myoma.     Amer.  J.  Rontgenology,  1916,  3,  72. 
Miller.     The  Control  of  Persistent  Uterine  Bleeding  Complicating  the  Meno- 
pause, Fibromyomata,  and  Carcinoma  of  the  Uterus  by  Radium.    South. 

Med.  Jour.,  1916,  9,  328. 
Pfahler.     Rontgentherapy    in    Uterine    Hemorrhage.      Jour.    Amer.    Med. 

Asso.,  1914,  (^Z^  628. 
Treatment  of  Uterine  Hemorrhage  by  X-rays.     Amer.  J.  Obst.,  1913, 

67,  860. 
• Rontgentherapy  in  Uterine  Fibroids  and  Uterine  Hemorrhage.     Amer. 

J.  Obst.,  1915,  72,  703. 
Pinkuss.     Die  Mesothoriumbehandlung  bei  Hamorrhagischen  Metropathien 

und  Myomen.     Deutsch.  Med.  Wchnsch.,  1913,  39,  1041. 
Stern.     X-ray  Treatment  of  Uterine  Fibroids,   Menorrhagia,   and   Metror- 
rhagia.    Amer.  J.  Obst.,  1913,  dj,  1132. 
WiLKiNs  and  Gervin.     Use  of  Radium  in  Treatment  of  Metrorrhagia  and 

Menorrhogia.     Radium,  1920,  14,  TJ. 


INDEX 


Abdominal  fistulae  as  source  of  vicarious 
menstruation,  265 

Abortion,  early,  dj'smenorrhea  differentiated 
from,  216 

hypertrophy  and  tortuosity  of  endome- 
trial glands  in,  233 

—  incomplete,    causing    uterine    hemorrhage, 

232 

— ■ 'Clinical  considerations,  232 

histological  findings,  233 

diagnosis  of,  by  chorionic  villi,  235 

by  decidual  cells,  234 

by  exaggerated  hypertrophy  and  tor- 
tuosity of  endometrial  glands,  233 

Acne,  menopausal,  134 

— ■  menstrual,  309 

—  at  puberty,  309 

Acute  exanthematous  diseases,  effects  of,  on 
menstruation,  298 

Adenocarcinoma  of  the  cervix,  uterine  hem- 
orrhage due  to,  239 

—  of  the  fundus,   distinguished   from  mem- 

branous dysmenorrhea,  217 

Adencwnyoma  of  the  uterus,  uterine  hemor- 
rhage due  to,  240 

Adipose  tissue,  increase  of,  at  menopause, 
137 

Adiposity,  amenorrhea  due  to,  174 

Adiposogenital  dystrophy,  277 

—  amenorrhea  associated  with,  174 

and  occurrence  of  pregnancy,  154 

organotherapy  in  treatment  of,  318 

Adiposogenital  syndrome  of  Frohlich,  pro- 
duced experimentally  in  animals  by  par- 
tial removal  of  the  hypophysis,  174 

Adnexitis,  uterine  hemorrhage  due  to,  243 
Adolescence,  101 

Ahlfeld's  table  of  time  of   fruitful  copula- 
tion in  relation  to  menstruation,  156 
Alcohol,  in  treatment  of  dysmenorrhea,  204 
Alcoholism,  amenorrhea  due  to,  307 
Alkaline   cervical   mucus,    role   of,    in   non- 
coagulability  of  menstrual  blood,  95 
Aloes,  in  treatment  of  amenorrhea,  180 
Amenorrhea,  in  adiposogenital  dystrophy,  277 
with  occurrence  of  pregnancy,  154 

—  —  organotherapy  for,  318 

—  in  alcoholism,  307 

—  causes    of,    acquired    pathological    condi- 

tions of  pelvic  organs,  169 

acute  infectious  diseases,  172 

adiposity,  174 


Amenorrhea  —  Continued 

'adiposogenital    dystrophy    of    Frohlich, 

174 

alcoholism,  173 

— ' — -atrophy  of  the  endometrium,  170 

^  chilling  of  body,  171 

change  of  climate,  171 

—  —  chlorosis,  172,  299 
— '  —  classification  of,  168 

—  — ^  congenital     absence    of    the    fallopian 

tubes,  169 

'Congenital   absence  of  uterus,   of  both 

ovaries,  or  of  both  uterus  and  ovaries, 
168 

constitutional  diseases,  172 

destruction  or  loss  of  function  of  se- 
creting ovarian  tissue,  170 

deterioration  in  general  health,  172 

—  —diabetes,   173 

— ' — 'diagnosis  of,  176 

disorders  of  ductless  glands,  173,  177 

"  dodging  periods "  of  puberty  and  the 

menopause,  170 

—  afunctional,  171 

-general,  168,  170 

'heredity,  173 

^h3'poplasia  of  uterus,  169 

— '  —  lactation,  171 

-lead  poisoning,  173 

local,  168 

mental  and  nervous  disorders,  173 

•  morphinism,  173 

— ' — -nephritis,  173 

— '  —  physical  and  mental  strain,  172 

— '  —  physiological,  170 

-pituitary  disease,  17'4 

pregnancy,  171 

— ' — -psychic  and  emotional,  171 

—  —  syphilis,  173 
— -  —  thyroid  disease,  173 
-tuberculosis,  172 

—  in  chlorosis,  172 

the  common  finding,  299 

— -  definition  of,  167 

—  in  diabetes,  302 

—  diagnosis  of  cause  of,  176  - 
— - — -distinction    between,    and    retention    of 

menses  and  suppression  of  menses,  167 

—  due  to  disorders  of  ductless  glands,  173  ■ 

—  diagnosis  of,  177 
— 'functional,  171 

'of  later  life,  organotherapy  for,  318 

—  in  Graves'  disease,  301 


336 


INDEX. 


Amenorrhea  —  Continued 

—  hypopituitary,  277 

—  inducement  of,  by  means  of  radium  and 

X-ray,  327 

effects    of    differentiated    from    oopho- 
rectomy amenorrhea,  330 

indications  for  intensity  of,  331 

—  influence  of  heredity  on,  173 

—  in  insanity,  307 

—  during  lactation,  cause  of,  163 
as  the  rule,  162 

—  of   menopause   and    of   pregnancy,    differ- 

entiated, 138 

—  in  morphinism,  307 

—  pathological,  and  adiposogenital  "dystrophy, 

with  occurrence  of  pregnancy,  154 

—  —  ovulation  during,  153 

—  pregnancy  during,  153 
. —  physiological.  170 

—  — diagnosis  of,  176 

—  primary,  167 

—  of  puberty,  170 

>— i  organotherapy  for,  317 

—  question  of  detriment  to  health,  174 

—  secondary,  167 

—  significance  of,  as  a  symptom,  174 

—  symptoms  associated  with,  absence  of,  176 
asthma,  175 

•r blindness,  175 

headache,  175 

local  and  general  discomfort,  176 

menstrual  leukorrhea  or  "  fluor  albus," 

176 

menstrual  molimina,  176 

i  neuroses  or  psychoses,  175 

ocular,  175 

—  due  to  syphilis,  297 

—  treatment  of,  avoidance  of  overwork,  178 
diet,  177 

by  emmenagogues,  aloes,  180 

apiol,  180 

^  —  manganese,  180 

•  —  questionable  value  of,  179 

various,  181 

-general  measures,  177 

by  hematinics,  178 

arsenic,  179 

iron,  178 

hot  baths  and  hot  drinks,  178 

-medicinal,  178 

open  air  recreation,  177 

of  underlying  cause,  177 

—  true,  167 

—  in  tuberculosis  more  common  than  menor- 

rhagia,  288 

—  explanation  of,  290 

—  practical  importance  of,  290 

—  in  typhoid  fever,  294 

—  Sec  also  Gynatresia 

Anemia,     due    to    menorrhagia,    treated    by 
radium  and  X-ray,  331 


Anemia  —  Continued 

— •  dysmenorrhea  due  to,  199 

Anestrous  cycle,  12 

Anestrum,  14 

Angioneurotic    edema,    of    menstrual    origin, 

308 
Anteflexion,  relation  of,  to  dysmenorrhea,  193 
Antithrombin,  formation  of,  by  endometriurn, 

and  non-coagulability  of  menstrual  blood, 

96 
Apiol,  in  treatment  of  amenorrhea,  180 

^of  dysmenorrhea,  205 

"  Apoplexia  uteri,"  238 

Arsenic,  in  treatment  of  amenorrhea,  179 

Arteriosclerosis    of    uterine    vessels,    uterine 

hemorrhage  due  to,  238 
Arthritis,  menstrual,  304 
Aschner's  studies  on  cause  of  menstruation, 

75 
Aspirin,  in  treatment  of  dysmenorrhea,  204  . 
Asthma,  associated  with,  amenorrhea,  175 
Atresia,   follicular,  and  origin  of  interstitial 

cells  of  ovary,  63 

—  senile,  gynatresia  due  to,  185 

Atretic    follicle,    origin    of    interstitial    cells 

from  walls  of,  63 
Atrophy    of    the    endometrium,    amenorrhea 

due  to,  170 
Atropin,  in  treatment  of  dysmenorrhea,  205,, 
Autotransplantation  of  ovarian  tissue,  272 
— ■  operative  technic,  273 

Bathing,  in  hygiene  of  puberty.  111 

—  at  menstrual  period,  111 

Belladonna,  in  treatment  of  dysmenorrhea, 
205 

Benzyl  benzoate  treatment  of  dysmenorrhea, 
208 

Blaud's  pill  in  treatment  of  amenorrhea,  ITS 

Bleeding  from  skin  in  vicarious  menstru- 
ation, 263 

Bleeding,  uterine.  See  Uterine  Hemorrhage. 

Blindness,  associated  with  amenorrhea,  175 

Blood,  amount  of,  lost  at  menstruation, 
amount  of  menstrual  discharge,  91 

individual  differences,  91 

— -  —  methods  of  estimating,  91 

^menstrual,  See  Menstrual  Blood 

Blood  injections,  in  treatment  of  uterine 
hemorrhage,  256 

Blood  picture,  influence  of  menstruation  ,Qn, 
92 

^  —  erythrocytes,  92 

— • — -hemoglobin,  92 

— •  —  leukocytes,  93 

—  — sugar  content  of  blood,  94 

Blood   pressure,   effect   of   menstruation  on, 

86,  87 
— -  relation  of  menstrual  vertigo  to,  133 
"  Bloody  sweat "  as  vicarious  menstruation, 

263 


INDEX. 


337 


Body  temperature,  effect  of  menstruation  on, 

85,86 
Bowels,  care  of,  in  hygiene  of  puberty,  112 
Breast  glands,  changes  in,  at  menopause,  137 
Breast  milk,  influence  of  menstruation  on,  164 
Bromids,  for  nervous  and  vasomotor  symp- 
toms of  menopause,  140 

—  in  treatment  of  dysmenorrhea,  205 

Cancer,  and  climacteric  hemorrhage,  143 

—  education  of  women  as  to  danger  of,  143 

—  of  the  cervix,  gynatresia  due  to,  186 

—  uterine,    climacteric    hemorrhage    suggest- 

ing, 139 

' diagnosis  of,  144 

responsibility  of  physician  in,  144 

Carcinoma  of  the  uterus,  uterine  hemorrhage 

due  to,  239 
Castration,   effects   of,   during  child  bearing 

age  of  woman,  271 
cause  of  symptoms,  272 

—  —  in  early  life,  270 
on  young  women,  129 

—  hypertrophy  of  pituitary  body  after,  278 

—  menstruation  aftei',  274 

Cervical  canal,  size  of,  during  menstruation. 
20 

Cervical  ectropion  and  erosion,  uterine 
hemorrhage  due  to,  232 

Cervical  mucus,  alkaline,  role  of,  in  non- 
coagulability  of  menstrual  blood,  95 

Cen^ical  polypi,  uterine  hemorrhage  due  to, 
231 

Cervix,  adenocarcinoma  of.  See  Adenocarci- 
noma of  the  cervix,  201 

—  dilatation    of,    continuous,    by    stem    pes- 

saries, in  treatment  of  dysmenorrhea,  210 
by  rapid  method,  in  treatment  of  dys- 
menorrhea, 209 

—  plastic  operations  on,  in  treatment  of  dys- 

menorrhea, 211 
Cervix  uteri,  changes  in,  at  menopause,  136 

—  role  of,  in  source  of  menstrual  flow,  19 
Chlorosis,  amenorrhea  due  to,  172 

—  characteristics  of,  298 

—  dysmenorrhea  due  to,  199 

—  effect  of,  on  menstruation,  299 
amenorrhea,  299 

dysmenorrhea,  300 

menorrhagia,  300 

—  effect  on,  of  menstruation,  300 

—  treatment  of  menstrual  disorders  of,  300 

harmfulness  of  emmenagogues,  300 

Cholelithiasis,  relation  between  menstruation 

and,  304 

Chorio-epithelioma,  uterine  bleeding  due  to, 
239 

Chorionic  villi,  signifying  incomplete  abor- 
tion, 235 

Cicatrices,  old,  hemorrhage  from,  in  vicarious 
menstruation,  264 


Climacteric,  See  Menopause 

"  Climacteric  hemorrhage,"  131,  246 

—  suggesting  uterine  cancer,  139,  143 

—  treatment  of,  139 
Climacterium,  See  Menopause 
Climate,  influence  of,  on  menopause,  127 
Clothing,  in  hygiene  of  puberty,  110 

Coal  tar  derivatives,  in  treatment  of  dys- 
menorrhea, 203 

Cocain  test  of  nasal  dysmenorrhea,  219 

Codein,  in  treatment  of  dysmenorrhea,  204 

Coitus,  and  menstruation,  superstitions  re- 
garding, 2,  5 

Cold  applications  to  abdomen,  for  uterine 
hemorrhage,  253 

Conception,  early  superstitions  regarding 
menstruation  and,  7 

— 'theory  of  menstruation  due  to  failure  of, 
69 

Congestion  of  endometrium  in  menstruation, 
25 

—  of  external  genitalia,  in  lower  animals,  12 

—  premenstrual,  stage  of,  25 
Convulsions,  in  hysteria  of  menstruation,  306 
Copulation,  fruitful,  in  relation  to  menstru- 
ation, Ahlfeld's  table  of,  156 

Corona  radiata,  42 

Corporeal  polypi,  uterine  hemorrhage  due  to,- 
232 

Corpus  albicans,  44,  52 

Corpus  fibrosum,  44 

Corpus  luteum,  appearance  of  yellow  in  wall 
of,  49,  50 

— 'Comparison  of  structure  of^  in  menstru- 
ation and  in  pregnancy,  55 

—  general,  43 

—  influence  of,  on  mammary  gland,  282 

—  life  cycle  of,  chronological  relation  of,  to 

menstrual  and  endometrial  cycles,  52 
— •  —  stage  of  maturity,  50 
stage  of  proliferation,  45 

—  —  stage  of  retrogression,  50 

stage  of  vascularization,  48 

^menstrual  cj-clic  changes  in,  time  relation 

between,  and  changes  in  endometrium,  54 
— 'modern  conception  of,  44 
— '  older  views  on,  43 
^origin  of  lutein  cells,  58 

—  rapidity  of  early  changes  in,  59 

—  very  early,  appearance  of,  47 

Corpus  luteum  cysts,  uterine  hemorrhage  due 
to,  243 

Corpus  luteum  extract,  in  treatment  of  men- 
strual disorders,  316 

—  in    amenorrhea    associated    with    adiposo- 

genital dystrophy,  319 
uterine  hemorrhage  of  menopause,  323 

—  — '  vasomotor  symptoms  of  menopause,  323 
Corpus  luteum  graviditatis,  condition  of,  dur-- 

ing  first  and  second  half  of  period,  57  , 


338 


INDEX. 


Corpus  luteum  menstruatlonis,  condition  of, 

before  and  after  menstruation,  57 
Corpus  luteum  spurium,  44,  55 
Corpus  luteum  theory  of  Fraenkel,  74 

—  conclusions  regarding,  7'7 

— •  recent  histological  confirmation  of,  76 

—  theories  against,  Aschner's,  75 
■  Halban's,  75 

Loeb's,  75 

—  —Marshall's,  74 

Theilhaber's,  74 

Corpus  luteum  verum,  44,  55 

Corpus  uteri,  changes  in,  at  menopause,  136 
Cotarnin  phthalate,   in   treatment  of   uterine 

hemorrhage,  255 
Cough,    influence    of    menstruation    on,    in 

tuberculosis,  293 
Curettage,    for    hyperplasia    and    associated 

uterine  bleeding,  248 

Decidual  cells  of  the  endometrium,  signify- 
ing incomplete  abortion,  324 

Dermatoses,  menstrual.  See  Menstrual  Der- 
matoses 

Deutoplasm  of  the  ovum,  43 

Diabetes,  amenorAea  due  to,  173 

—  effect  of,  on  menstruation,  302 

—  effect  on,  of  menstruation,  302 

—  examination  for,  at  menopause,  141 
Discus  proligerus,  42 

Di-estrous  cycle,  14 

Diet,  in  hygiene  of  puberty.  111 

—  in  treatment  of  amenorrhea,  17'7 
Diffuse  virginal  hypertrophy  of  breasts,  100 
Dilatation    of    cervix,    continuous,    by    stem 

pessaries,  in  treatment  of  dysmenorrhea, 
210 

—  by    rapid    method,    in    treatment    of    dys- 

menorrhea, primary,  209 

Discharge  from  generative  tract,  in  lower 
animals,  12 

Douches,  hot  vaginal,  for  uterine  hemor- 
rhage, 253 

Drugs,  in  treatment  of  amenorrhea,  178 

arsenic,  179 

emmenagogues,  179 

aloes,  180 

apiol,  180 

■ — •manganese,  180 

'hematinics,  178 

iron,  178 

-various,  181 

—  in  treatment  of  chlorosis,  harmfulness  of 

emmenagogues,  300 

—  in  treatment  of  dysmenorrhea,  203 

—  —  alcohol,  204 

apiol,  205 

aspirin,  204 

atropin,  205 

: belladonna,  205 

*—— benzyl  benzoate,  208 


Drugs  —  Continued 

"bromids,  205 

'Cannabis  indica,  205 

coal  tar  derivatives,  203 

^  — codein,  204 
— ■  —  gelsemium,  205 

-guaiacum,  204 

— •  —  helonin,  205 

hydrastis,  205 

— •  —  morphin,  204 
— '  —  opium,  204 

piscidia  erythema,  205 

'Pulsatilla,  205 

— '  —  pyramidon,  204 

— ■  —  viburnum  prunifolium,  205 

— 'treatment  of  menopausal  disturbances,  139 

—  in   treatment   of   uterine  hemorrhage,   co- 

tarnin phthalate,  255 

—  —  ergot,  254 

— '  —  hydrastis,  255 

— '  —  for  internal  administration,  255 

— •  —  intra-uterine  application  of,  255 

Ductless  glands,  See  Endocrine  Glands 

Dysmenorrhea,  causes  of,  increased  irrita- 
bility of  autonomic  nerve  endings  in  the 
uterus,  atropin  for,  206 

— •  causes  of  primary  form  of,  general  con- 
siderations, 191 

— •  —  hypoplasia  of  reproductive  organs,  193 

hysteria,  197 

•  mechanical  obstruction  of  uterine  gland, 

192 

neuralgia,  199 

— •  —  neurasthenia,  198 

— •  —  neuroses,  196 

—  causes  of  secondary  form  of,  chlorosis  and 

other  forms  of  anemia,  199 
— ' — 'Constitutional  disease,  199,  200 
— •  —  general  considerations,  199 
— ■ — 'inflammatory  disease  of  pelvic  organs, 

201 
— • — 'local  pelvic  disease,  200 

myomata  of  uterus,  202 

— ■  —  retrodisplacement  of  uterus,  201 
'tuberculosis,  200 

—  in  chlorosis,  300 

—  classification    of,    from    the    ray    therapy 

standpoint,  331 
— '  clinical    characteristics    of,    in    spasmodic 
dysmenorrhea,  202,  203 

—  clinical  types  of,  202 

—  congestive,  191 

—  definition  of,  190 

-^  differentiated  from  early  abortion,  216 

—  differentiated    from    moderate    discomfort 

of  menstruation,  190 

—  frequency  of,  191 
^general  considerations,  190 

—  hysterical,  197 

—  membranous,  clinical  characteristics  of,  212 
diagnosis  of,  215 


INDEX. 


339 


Dysmenorrhea  —  Continued 

differentiated   from  adenocarcinoma  of 

the  fundus,  217 
from  a  sloughing,  submucous  myoma, 

217 

from  vaginal  membranes,  217 

endometrial  membranes,  215 

etiology  of,  212 

fibrinous  membranes,  215 

general  considerations,  211 

mechanism  of  detachment  of  membrane, 

213 

prognosis  of,  217 

structure  of  menstrual  membranes,  214 

treatment  of,  217 

—  nasal,  cocain  test  of,  219 

cocainization  of  genital  spots,  219 

need  of  caution  in  estimating  results 

of  treatment,  220 
general  considerations,  218 

—  — "genital  spots"  in  the  nose,  218 

method  of  treatment,  220 

permanent  cure  of,  219 

theories  of  nature  of  relation  between 

generative  organs  and  the  nose,  218. 
— •  neuralgic,  199 

—  neurasthenic,  198 

—  obstructive,  192 

—  organotherapy  of,  324 

—  primary,  191 
causes  of,  191 

—  relation  of  anteflexion  to,  193  ' 

—  secondary,  191 
causes  of,  199 

—  spasmodic,  191 

—  —  clinical  characteristics  of,  202,  203 
in  hysteria  of  menstruation,  306 

—  treatment  of,  general  considerations,  203 
for  permanent  relief,  208 

for  permanent   relief  of  primary  type, 

209 
dilatation   of    cervix,   continuous,   by 

stem  pessaries,  210 
dilatation  of  cervix  by  rapid  method, 

209 

■  —  importance  of  accurate  diagnosis,  209 

■  —  plastic  operations  on  cervix,  211 

for  permanent  cure  of  secondary  type, 

211 

by  radium  and  X-ray,  332 

■  spasmodic,    during    attack,    by    benzyl 

benzoate,  208 

mammary,  208 

i  symptomatic,     during     attack,     atropin 

treatment,  205 

'drugs,  203 

general  measure,  203 

— •  in  tuberculosis,  291 

—  types  of,  Kelly's  division,   spasmodic  and 

congestive,  191 

—  —  primary  and  secondary,  191 


"  Dysmenorrhea  apoplectica,"  212 
Dyspepsia  uterina,  at  menopause,  134 
Dyspnea,    influence    of    menstruation    on,    in 

tulicrculosis,  293 
Dystrophy,      adiposogenital,      of      Frohlich, 

amenorrhea  due  to,  174 
associated  with  pathological  amenorrhea 

and  occurrence  of  pregnancy,  154 

Ecchymoses,  menstrual,  309 

Ectopic  pregnancy,  uterine  hemorrhage  due 
to,  242 

Ectropion  and  erosion,  cervical,  uterine 
hemorrhage  due  to,  232 

Edema,  angioneurotic,  of  menstrual  origin, 
308 

Education  of  women  as  to  danger  of  cancer, 
143 

Embryological  studies  of  relation  of  ovula- 
tion and  menstruation,  155 

Emmenagogues,  harmfulness  of,  in  treatment 
of  chlorosis,  300 

— •  in  treatment  of  amenorrhea,  aloes,  180 

apiol,  180 

— •  —  manganese,  180 

— •  —  questionable  value  of,  179 

— •  —  various,  181 

Emotional  disturbances,  amenorrhea  due  to, 
171 

Endocrine  glands,  characteristics  of  en- 
docrine bodies,  269 

— ■  disorders  of,  uterine  hemorrhage  due  to, 
245 

— 'influence  of,  on  menstruation,  of  glands 
other  than  ovary,  78 

— •  —  ovary  as  underlying  cause,  73 

—  mammary,  282 

— •  and  menstruation,   See   Menstruation  and 

the  Endocrine  Glands 
— '  pancreas,  283 

—  ovary,   disorders  of,  with  uterine  hemor- 

rhage, 244 

—  pineal  body,  280 

— ■  —  feeding  experiments,  281 

'results  of  extirpation,  281 

'  so-called  pineal  syndrome,  280 

—  pituitary   body,    adiposogenital    dystrophy, 

277 

—  —  hypertrophy  of,  after  castration,  278 
' — 'in  pregnancy,  278 

— ■  —  influence  of,  on  body  growth,  278 
— ■ — 'relation  of,  to  generative  organs,  277 

—  principal    endocrine    structures    and    their 

importance  to  the  body  economy,  269 

—  role  of,  in  uterine  hemorrhage,  247 

—  suprarenal   bodies,    difference  in   function 

between  cortex  and  medulla,  279 

-effects     of     hyperplasia     of,     without 

tumors,  on  reproductive  system,  280 

—  —  effects   of  tumors   of,   on  reproductive 

system,  279 


340 


INDEX. 


Endocrine  glands  —  Continued 

hypoplasia  of,  associated  with  retarded 

sexual  development,  280 

—  thymus,  281 

—  thyroid,  disease  of,  as  a  result  of  pelvic 

lesions,  276 

menstrual  disorders  accompanying  thy- 
roid disease,  276 

relation  of,  to  gonads,  276 

Endocrinopathy,  nature  of,  250 

Endometrial  cycles,  chronological  relation  of 
corpus  luteum  cycle  to,  52 

Endometrial  membranes,  in  membranous 
dysmenorrhea,  215 

Endometritis,  exfoliative,  213 

—  uterine  hemorrhage  due  to,  235 
Endometritis  necrobiotica,  247 
Endometrium,    atrophy   of,   amenorrhea    due 

to,  170 

—  biological  role  of,  as  factor  in  non-coagu- 

lability of  menstrual  blood,  97 

—  changes  in,  at  menopause,  136 

during  menstruation,  histological,  26 

epithelial,  31 

interval  stage,  29 

menstrual  stage,  30 

postmenstrual  stage,  29 

premenstrual  stage,  29 

proliferative  stage,  31 

secretory  stage,  31 

stage  of  desquamation  and  degen- 
eration, 31 

stromal,  34 

glandular,  33 

macroscopic,  25 

—  congestion  and  increased  thickness  of,  in 

menstruation,  25 

—  decidual    cells    of,    signifying    incomplete 

abortion,  234 

—  determination  of  stage  of  removal  of,  44 

—  formation   of    antithrombin   by,   and   non- 

coagulability  of  menstrual  blood,  96 

—  glands    of,    exaggerated   hypertrophy    and 

tortuosity  characterizing  only  pregnancy, 
233 

—  hyperplasia    of,    a    constant    finding    with 

functional  uterine  hemorrhage,  249 
with    excessive    menstruation,    in    very 

young  patients,  247 

ovarian  element  concerned  in,  250 

uterine  hemorrhage  due  to,  235 

curettage  for,  248 

—  as  local  factor  in  menstruation,  78 

—  menstrual  cyclic  changes  in,  time  relation 

between,  and  changes  in  corpus  luteum, 
54 

—  normal,  glands  of,  26 

epithelium  of,  26 

stroma  of,  26 

fc- — structure  of,  26 


Endometrium  —  Continued 

—  possibility   of    local    factor  in,   explaining 

non-coagulability  of  menstrual  blood,  96 

—  premenstrual   hypertrophy   of,    degree   of, 

195 

—  subservience  of,  to  the  ovary,  249 

—  uterine  hemorrhage  due  to,  local  factor  in, 

246 
Epilepsy,  and  menstruation,  relation  of,  305 
Epiphyseal  union,  delayed  and  early,  113 
Epistaxis,  vicarious  menstruation  in  form  of, 

261 
Epithelial  envelope  of  ovary,  42 
Epithelial  origin  of  lutein  cells,  theory  of,  58 
Epithelium  of  the  endometrium,  26 

—  changes  in  during  menstrual  cycle,  31 
Ergot,  in  treatment  of  uterine  hemorrhage, 

254 
Erosion     and     ectropion,     cervical,     uterine 

hemorrhage  due  to,  232 
Erysipelas,  menstrual,  309 

—  pseudo,  menstrual,  309 
Erythema,  menstrual,  308 
Erythema  multiforme,  menstrual,  309 
Erythema  nodosum,  menstrual,  309 
Erythrocytes,   influence  of  menstruation  on, 

92 
Estrous  cycle  in  various  animals,  14 
Estrus,  11 
Estrus,  abnormal,  13 

—  analogy  between  phenomena  of,  and  men- 

struation, 16 

—  period  of,  13 

—  relation  of   ovulation  and,   in  lower  ani- 

mals, 150 

"  Evolutio  precox  corporis,"  115 

Exanthematous  diseases,  acute,  eflfect  of,  on 
menstruation,  298 

"  Exfoliative  endometritis,"  213 

External  hemorrhage  of  menstruation,  stage 
of,  25 

Eye  and  eyelids,  hemorrhage  from,  in  vicari- 
ous menstruation,  264 

Fallopian   tubes,  changes   in,  at  menopause, 

137 
at  puberty,  101 

—  congenital  absence  of,  amenorrhea  due  to, 

169 

—  question   of  participation  of,  in  menstru- 

ation, 20 

clinical  evidence,  20 

histological  evidence,  21 

—  tumors  of,  uterine  hemorrhage  due  to,  244 
Febris  intermenstrualis,  293 

Ferment  theory  of  menstruation,  67 
"  Fervor  uterinus  "  of  Democritus,  67 
Fever,  in  tuberculosis,  postmenstrual,  293 

premenstrual,  292 

various,  293 


INDEX 


341 


Fever  —  Continued 

—  ill  typhoid,  intlucnce  of  menstruation  on, 

296 
Fibrin    ferment,    absence    of,    in    menstrual 

blood,  96 
Fistulae,    abdominal,   as   source   of   vicarious 

menstruation,  265 
"Fluor  albus,"  and  amenorrhea,  176 
Flushes  of  menopause,  132 

—  treatment  of,  140 

Follicles  of  the  ovary,  Graafian,  42 

—  primordial,  42 

—  rupture  of,  changes  preceding,  45 
process  of,  46 

Follicular  atresia,  production  of  interstitial 
cells  due  to,  63 

Fowler's  solution,  for  treatment  of  amenor- 
rhea, 179 

Fraenkel's  corpus  luteum  theory  of  menstru- 
ation, 74 

Galen's  plethora  theory  of  menstruation,  67 
Gastric  disturbances,  at  menopause,  134 
Gas'tro-intestinal  diseases,  and  menstruation, 

reciprocal  relations  of,  303 
Generative  glands,   relation  to,   of   pituitary 

body,  277 
of  thyroid  gland,  276 

—  tumors     of,     associated    with     precocious 

menstruation,  117 
Generative    organs,    relation    betvi^een    nose 
and,  218 

—  relation    between    suprarenal    bodies    and, 

279 
' — tuberculosis    of,    uterine    hemorrhage    due 

to,  242 
Genital   hemorrhage,    non-menstrual,    of   the 

new    born.    See    Non-menstrual    Genital 

Hemorrhage 
"  Genital  spots  "  in  the  nose,  218 
Genitalia,  external,  changes  in,  at  menopause, 

135 
changes  in,  at  puberty,  101 

—  internal,    anatomic    changes    in,    at   meno- 

pause, 136 
Germinal  spot,  43 
Germinal  vesiicle,  43 
Glands  of  the  endometrium,  26 

—  changes  in,  during  menstrual  cycle,  33 
Gonads,    relation   between   pineal  body   and, 

280 

—  relation  between  pituitary  body  and,  277 

—  relation  between  suprarenal  bodies  and,  279 

—  relation  between  thyroid   gland  and,    evi- 

dences of,  276 
Graafian    follicle    cysts,    uterine   hemorrhage 

due  to,  243 
Grave's   disease,  effect  of,   on   menstruation, 

301 
Guaiacum,  in  treatment  of  dysmenorrhea,  204 


Gynatresia,  causes  of,  imperforate  hymen,  184 

Nagel-Veit  theory,  183 

in  primary  or  congenital  type,  183 

—  —  in    secondary   or   acquired    type,    carci- 

noma of  the  cervix,  186 

infectious  diseases,  185 

— ■ mechanical  occlusion  from  within  or 

without  the  genital  canal,  186 

peurperal   infection   or   lacerations,    184 

— • senile  atresia,  185 

torsion,  186 

trauma,  185 

wearing    of    anti-pregnancy    button, 

186 

— •  —  various  forms  of  obstruction,  184 

— 'Chemical  composition  of  retained  men- 
strual discharge,  187 

—  definition  of,  183 

—  diagnosis  of,  187 

— -hematosalpinx  in  cases  of,  causes  of,  187 
— 'location  of  obstructing  membrane,   184 

—  Nagel-Veit  theory,  183 

—  primary  or  congenital,  causes  of,  183 

—  prognosis  of,  188 

—  secondary  or  acquired,  causes  of,  184 
■ — symptoms  of,  187 

—  treatment  of,  188 

—  types  of,  primary  or  congenital,  183 
— ■  —  secondary,  or  acquired,  184 

Halban's  theory  of  menstruation,  75 
Headache,  associated  with  amenorrhea,  175 

—  as  a  symptom  of  menopause,  134 
"Heat"  or  estrus,  11 

Helonin,  in  treatment  of  dysmenorrhea,  205 

Hematidrosis,  264 

Hematinics,  in  treatment  of  amenorrhea,  178 

arsenic,  179 

iron,  178 

Hematomata,  subepithelial,  25,  35 

Hematometra,  184,  186 

— -in  typhoid  fever,  295 

Hematosalpinx,  in  cases  of  gynatresia,  cause 

of,  187 
Hematuria,  vicarious  menstruation   in   form 

of,  264 
Hemoglobin,  influence  of  menstruation  on,  92 
Hemophilia,  effect  of,  on  menstruation,  301 
Hemoptysis,    of    tuberculosis,     influence    of 

menstruation  on,  294 
Hemorrhage,  climacteric,  131 

suggesting  uterine  cancer,  139,  143 

treatment  of,  139 

—  from  nasal  mucous  membrane,  in  vicarious 

menstruation,  261 

—  non-menstrual    genital,   of   the   new   bom. 

See  Non-menstrual  Genital  Hemorrhage 

—  of  puberty,  246 

—  uterine,  See  Uterine  Hemorrhage 


342 


INDEX. 


Hemorrhage  —  Continued 
•■ —  in  vicarious  menstruation,  from  abdominal 
fistulae,  265 

from  eye  and  eyelids,  264 

from  intestinal  canal,  262 

from  kidneys,  264 

from  lips,  264 

from  lungs,  262 

from  mammary  glands,  263 

from  nevi,  264 

from  nipple,  263 

from  old  cicatrices,  264 

from  skin,  263 

from  stomach,  262 

from  umbilicus,  265 

from  various  sources,  265 

Heredity,  influence  of,  in  amenoirhea,  173 
on  menopause,  128 

—  and  menopausal  psychopathies,  147 
Herpes,  menstrual,  308 
Hormones,  sympathicotropic,  245 

—  vagotropic,  245 

Hot  baths  and  hot   drinks  in  treatment  of 

amenorrhea,  178 
Hot  flashes  of  menopause,  132 
■ — treatment  of,  140 
Hot  vaginal  douches,  for  uterine  hemorrhage, 

253 
Hydatidiform  mole,  uterine  hemorrhage  due 

to,  239 
Hydrastis,  in  treatment  of  dysmenorrhea,  205 

■ of  uterine  hemorrhage,  255 

Hygiene  of  menopause.  See  Menopause 
Hygiene  of  puberty.  See  Puberty 
Hygiene,  sex,  See  Sex  Hygiene 
Hymen,  imperforate,  gynatresia  due  to,  184 
Hyperemia,  of  the  liver,  menstrual,  303 

—  pelvic,  in  menstruation,  25 
Hypergonadism,  250 

—  uterine  hemorrhage  due  to,  244 
Hyperoophorism,  uterine  hemorrhage  due  to, 

244 
Hyperplasia  of  the  endometrium,  a  constant 
finding  with    functional    uterine   hemor- 
rhage, 249 

—  with     excessive     menstruation,     in     very 

young  patients,  247 

—  ovarian  element  concerned  in,  250 

—  uterine  hemorrhage  due  to,  235 
curettage  for,  248 

Hypersecretion  of  ovary,  uterine  hemorrhage 
due  to,  244 

Hypertension,  vacillating,  of  menopause,  133 

Hyperthyroidism,  effect  of,  on  menstruation, 
30^ 

Hypertrophy,  of  the  breasts,  "diffuse  vir- 
ginal," 100 

as  symptom  of  premature  development, 

116 

i-of  endometrium,  premenstrual,  degree  of, 
195 


Hypertrophy  —  Continued 

—  suprarenal,    associated    with    changes    in 

sexual  apparatus,  280 
Hypogonadism,  250 

—  female,  uterine  hemorrhage  due  to,  250 
Hypoplasia,    of     reproductive    organs,     dys- 
menorrhea due  to,  193 

—  suprarenal,  associated  with  retarded  sexual 

development,  280 

—  of  the  uterus,  amenorrhea  due  to,  169 
Hypoplastic  uterus,  histological  reaction  of, 

to  menstruation,  195 

Hypothyroidism,  menorrhagia  of,  thyroid  ex- 
tract in  treatment  of,  321 

Hysterectomy,  conservation  of  ovarian  tissue 
in,  130 

Hysteria,  and  menstruation,  relation  of,  306 

Hysterical  dysmenorrhea,  197 

Icterus  menstrualis,  303 

Imperforate  hymen,  gynatresia  due  to,  184 

Infantile  uterus,  dysmenorrhea  due  to,  193 

—  dysmenorrhea  and  sterility  due  to,  194 

—  preponderance  of  connective  tissue  in,  195 
Infectious  diseases,  acute,  amenorrhea  due  to, 

172 

—  effect  of,  on  menstruation,  298 

—  gynatresia  due  to,  185 

Inilammatory  disease,  of  the  adnexa,  uterine 
hemorrhage  due  to,  243 

—  of  pelvic  organs,  dysmenorrhea  due  to,  201 
Influenza,  effect  of,  on  menstruation,  298 
Injection  experiments  with  ovarian  extract, 

77 

Injections  of  blood  and  serum,  in  treatment 
of  uterine  hemorrhage,  256 

Insanity,  of  menopause,  133 ;  See  also  Meno- 
pause, Psychopathies  of 

—  and  menstruation,  relation  of,  307 
Insomnia,  of  menopause,  treatment  of,  140 
"  Insufficientia  uteri,"  of  Theilhaber,  238 
Intermenstrual  fever,  in  tuberculosis,  293 
Intermenstrual  pain,  age  of  patients,  225 

— 'associated  pelvic  lesions,  226 

—  associated  vaginal  discharge,  225 

—  character  of,  225 

— -character  of  menstruation,  226 

—  definition  of,  224 
— 'duration  of,  225 

—  etiology  of,  226 

—  frequency  of,  224 

—  location  of,  225 

—  marital  and  obstetrical  histories  of  patients, 

226 

—  time  of  occurrence  of  attacks,  224 
— 'treatment  of,  227 

Interstitial  cells  of  the  ovary,  general,  60 

—  human,  61 

—  in  lower  animals,  61 

—  origin  of,  from  walls  of  atretic  follicle,  63 
Interval  between  menstrual  periods,  89 


INDEX. 


343 


Interval  S'tage  in  endometrium,  29 

Intestinal  canal,  as  source  of  vicarious  men- 
struation, 262 

Intoxications,  chronic,  and  menstruation,  re- 
lation of,  307 

lodid  of  iron,  syrup  of,  in  treatment  of 
amenorrhea,  179 

Iron,  in  treatment  of  amenorrhea,  178 

Jaundice,  menstrual,  303 

Joint     diseases,     and     menstruation,     acute 

articular  rheumatism,  304 
"menstrual  arthritis,"  304 

Kelly's  prescriptions  for  treatment  of  local 
disturbances  of  menopause,  141 

Kidneys,  source  of  vicarious  menstruation, 
264 

Knee  jerk,  effect  of  menstruation  on,  88 

Lactation,  abnormal,  at  time  of  menstruation, 
263 

—  amenorrhea  during,  171 
cause  of,  163 

the  rule,  162 

—  and  menstruation,   relation  of.    See  Men- 

struation and  Lactation 
■ —  ovulation  during,  153,  164 

—  reappearance  of  menstruation  before  end 

of,  162 
Leukemia,  effect  of,  on  menstruation,  300 
Leukocytes,  influence  of  menstruation  on,  93 
Leukorrhea,  menstrual,  and  amenorrhea,  176 
"  Libido  sexualis  "  and  menstruation,  84 
Lips,   hemorrhage   from,   in  vicarious   men- 
struation, 264 
Liquor  folliculi,  42 
• —  evacuation  of,  46 
Liver  diseases,  cholelithiasis,  304 

—  menstrual  hyperemia  of  the  liver,  303 

—  menstrual  jaundice    (icterus  menstrualis), 

303 

Loeb's  theory  of  menstruation,  7'5 

Lungs,  hemorrhage  from,  in  vicarious  men- 
struation, 262 

Lutein  cells,  fatty  changes  in,  significance  of, 
52  _ 

■ —  origin  of,  58 

from  connective  tissue,  theory  of,  58 

epithelial,  theory  of,  58 

in  lovi^er  animals,  58 

present  status  of  question,  60 

■ two  principal  theories,  58 

Mall's  theory  of  relation  of   ovulation  and 

menstruation,  156 
Mammary  gland,  causes  for  increased  size  of, 

in  pregnancy,  282 

—  as  source  of  vicarious  menstruation,  263 
! —  relation  between  corpus  luteum  and,  282 

—  relation  between  fetus  and,  282 


Mammary  gland  —  Continued 

— •  relation  between  ovaries  and,  282 

—  relation  between  uterus  and,  282 
Mammary     hypertrophy,     as     symptom     of 

premature  development,  116 
Mammary  treatment  of  dysmenorrhea,  208 
Manganese,  in  treatment  of  amenorrhea,  180 
Marital  state,  influence  of,  on  psychopathies 

of  menopause,  146 
Marshall's  theory  of  menstruation,  74 
Maternity,  and  menopause,  127 
Maturity,    precocious,    and    precocious    men- 
struation, 113 
Maturity  of  corpus  luteum,  stage  of,  50 
Melancholia,  associated  with  menopause,  148 
Membrana  granulosa  of  ovary,  42 
Membranous  dysmenorrhea.  See  Dysmenor- 
rhea,  Membranous 
Menopause,  age  for  occurrence  of,  126 
— •  —  factors  influencing,  127 

—  anatomic  changes  of,  in  breast  glands,  137 
in  external  genitalia,  135 

increase  of  adipose  tissue,  137 

— •  —  in  internal  genitalia,  136 

—  artificial,  129 

— ■  —  cause  of  symptoms  of,  272 
manifestations  of,  271 

—  climacteric  hemorrhage  of,  131 

—  and  cancer,  143 

—  climatic  influence  on,  127 

—  definition  of,  125 

—  delayed,  129 

—  diagnosis  of,  137' 

^differentiated   from  amenorrhea   of  preg- 
nancy, 138 

—  "dodging  period"  of,  amenorrhea  during, 

170 

—  duration  of,  130 

—  early,  128 

— •  examination  for  cancer,  139 

—  examination  of  urine  for  sugar,  141 

—  factors  influencing  age  of,  127,  128 
— •  —  climate,  127 

heredity,  128 

maternity,  127 

obesity,  128 

'race,  128 

— -  —  social  condition,  128 

wasting  diseases,  128 

— ■  factors  influencing  severity  of,  134 

—  hemorrhage  of,  246 

—  and  heredity,  128 

—  historical  considerations,  125 

—  hygiene    of,    education    of    women    as    to 

danger  of  cancer,  143 

general  measures,  143 

— -and  increases  of  adipose  tissue,  137 

—  increase  in  sexual  appetite  during,  134 
— 'and  insanity,  133 

— ■  and  maternity,  127 

—  menorrhagia  due  to,  131 


344 


INDEX. 


IMenopause  —  Continued 

'Ovarian  extract  in  treatment  of,  323 

—  and  menstrual  vertigo,  133 

—  and  mental  disorders,  307 

—  and  metrorrhagia,  131 
— •  and  obesity,  128 

—  ovulation  after,  153 

—  ovulation  during  "  dodging  period  "  of,  152 

—  part  played  by  ovary  at,  270 

—  and  pelvic  disease,  128 

—  psychopathies  of,  age  of  patients,  146 
correlated  causes,  147 

delusional,  148 

illustrations  of  types  of,  148 

'incidence  of,  146 

influence  of  heredity,  147 

influence  of  marital  state,  146 

'maniacal,  148 

-melancholic,  148 

paranoia,  148 

'previous  attacks,  147 

prodromal  symptoms,  147 

— •  —  prognosis  of,  148 

sensory  neuroses  of  throat,  147 

sexual,  147 

suicidal,  148 

types  of  disorders,  147 

—  racial  influence  on,  128 

— 'ray,  effect  of,  differentiated  from  oopho- 
rectomy amenorrhea,  330 

—  sensory  neuroses  of  throat  associated  with, 

147 
— 'Sexual  character  of  psychoses  of,  147 

—  and  social  condition,  128 

—  surgical,  See  Menopause,  Artificial 

—  symptoms   of,   cessation  of    menstruation, 

131 

flushes,  132 

— •  —  gastric,  134 

general  course,  130 

-headache,  134 

'hot  flashes,  132 

insomnia,  140 

— ' — -nervous,  133 

numbness  or  tingling,  133 

.pruritis,  133 

—  — -psychic,  133 

— '  —  skin  eruptions,  134 
• — '  —  sweating,  133 

tachycardia,  133 

-vasomotor,  132 

■ vertigo,  133,  134 

— throat  disturbances  associated  with,  147 
-=- treatment  of  disturbances  of,  by  drugs,  139 

flushes,  140 

general,  139 

hemorrhage,  139 

hot  flashes,  140 

. insomnia,  140 

local,  141 

mental,  140 


Menopause  —  Continued  ^ 

'nervous  symptoms,  140 

by  organotherapy,  323 

pruritis  vulvae,  141 

by  radium,  141 

senile  vulvovaginitis,  141 

— '  —  sweating,  140 
— ' — -vasomotor,  140 

—  "  vacillating  hypertension  "  of,  133 

— ^  vasomotor  symptoms  of,  organotherapy  of, 

323 
— ■  and  wasting  diseases,  128 
Menorrhagia,  causes  of,  discussed  with  those 

of  metrorrhagia,  229 
— '  in  chlorosis,  300 

—  due  to  atony  of  uterine  muscle,  pituitary 

extract  in  treatment  of,  322 
— -  functional,  of  menopause,  ovarian  extract 

in  treatment  of,  323 
— '  —  of  puberty,  thyroid  extract  in  treatment 

of,  322 

—  in  Graves'  disease,  301 

—  of     hypothyroidism,     thyroid     extract     in 

treatment  of,  321 
^in  leukemia,  301 

—  and  the  menopause,  131 
— •  in  myxedema,  302 

— 'treatment  of,  by  organotherapy,  321,  322, 
323 

—  — 'by  radium  and  X-ray,  331 

—  in  tuberculosis,  290 

— '  —  less  common  than  amenorrhea,  288 
"  Menorrhalgia,"  190 
'■  Menorrhemia,"  due  to  amenorrhea,  175 
^in  syphilis,  297 

—  and  thyroid  disease,  276 
Menstrual  arthritis,  304 

Menstrual  blood,  absence  of  fibrin  ferment 
in,  96 

—  difference  between  venous  blood  and,  94 

—  non-coagulability  of,  95 

— ' — -and  absence  of  fibrin  ferment,  96 
— ' — 'biological  role  of  the  endometrium  as 
factor  in,  97 

—  — 'differences  of  opinion  regarding,  95 

— ' — .formation  of  antlthrombin  by  the  endo- 
metrium, 96 

-importance  of  problem,  95 

— '  —  possible  Influence  of  changes  in  coagu- 
lating time  of  body  blood  at  time  of 
menstruation,  96 

— '  —  possibility  of  a  local  factor  in  the  endo- 
metrium, 96 

— •  —  role  of  alkaline  cervical  mucus  in,  95 

Menstrual  center,  theory  of,  70 

Menstrual  cyclic  changes,  in  the  ovary,  40 

— ■  —  consideration  of  follicles,  42 

— '  —  corpus  luteum,  43 

— - — '  —  chronological  relation  to  menstrual 
and  endometrial  cycles,  52 


INDEX. 


345 


Menstrual  cyclic  changes  —  Continued 

comparison  of,   in  menstruation   and 

in  pregnancy,  55 

gross  anatomy  of  ovary,  40 

'histologj^  of  ovary,  41 

rtiacroscopic,  40 

— ■  anatomic,  stage  of  external  hemorrhage,  25 

stage  of  postmenstrual  regeneration, 

25 

stage  of  premenstrual  congestion,  25 

chronological  relation  of  corpus  luteum 

cycle  to,  52 

in  the  endometrium,  histological,  26 

in  the  endometrium,  histological,  de- 
velopmental cycle,  28 

epithelial,  31 

glandular,  33 

interval  stage,  29 

menstrual  stage,  30 

modern  view^s  as  to,  26 

postmenstrual  stage,  29 

premenstrual  stage,  29 

proliferative  stage,  31 

secretory  stage^  31 

■ — stage  of  desquamation  and  degen- 
eration, 31 

stromal,  34 

macroscopic,  25 

historical,  24 

Hitschmann  and  Adler's  division,  27 

pelvic  hyperemia,  25 

■ question  of  loss  of  uterine  mucosa,  36 

macroscopic,  25 

Schroder's  division,  31 

vascular,  35 

Menstrual  date,  relation  of,  to  onset  of 
typhoid  fever,  295 

Menstrual  dermatoses,  acne,  309 

—  angioneurotic  edema,  308 

—  ecchymoses,  309 

—  erysipelas,  309 

—  erythema,  308 

—  erythema  nodosum,  309 
— 'herpes,  308 

—  occurrence  of,  307 

—  pigmentation,  310 

—  urticaria,  308 

Menstrual  discharge,  amount  of,  91 

—  nature  of,  94 

—  retained,    in   gynatresia,    chemical   compo- 

sition of,  187 

—  not  usually  dependent  on  local  lesions  in 

pelvis,  289 
— treatment    of,    by   organotherapy   of.    See 

Organotherapy 
by  radium  and  X-ray,  See  Radium  and 

X-ray  Treatment  of  Menstrual  Disorders 
Menstrual   flow,   abnormality  of,  treated  by 

radium  and  X-ray,  331 

—  average  amount  of  blood  given  off  during, 

192 


Menstrual  flow  —  Continued 

—  duration  of  period  of,  90 

— •endometrium  as  source  of,  19 

—  interval  between  periods,  89 
— 'Periodicity  of,  88 

—  source  of,  19 

—  —  question    of    participation    of    fallopian 

tubes,  20 

role  of  cervix  uteri,  19 

Menstrual  history  in  cases  of  vicarious  men- 
struation, 265 

Menstrual  hyperemia  of  the  liver,  303 

Menstrual  jaundice,  303 

Menstrual  leukorrhea,  associated  with 
amenorrhea,  176 

Menstrual  membranes,  endometrial,  215 

— ■  fibrinous,  215 

—  structure  of,  macroscopic  appearance,  214 
— ■  —  microscopic,  215 

Menstrual  molimena,  81 

—  in  mechanical  occlusion  of  genital   canal, 

176 
Menstrual  periods,  bathing  before  and  dur- 
ing, 111 

—  duration  of,  90 

— •  interval  between,  89 
Menstrual  stage  of  endometrium,  30 
Menstrual  vertigo,  relation  of,  to  blood  pres- 
sure, 133 
"  Menstrual  wave  "  theory,  85 

—  and  tuberculosis,  292 

"  Menstruatio  precox,"  115 
Menstruation,  and  acne,  309 

—  and  acute  exanthematous  diseases,  298 

—  amount  of  blood  lost,  amount  of  menstrual 

discharge,  91 

individual  differences,  91 

— ■  —  methods  of  estimating,  91 

— •  analogy  between  phenomena  of  estrus  and, 

16 
— 'and  angioneurotic  edema,  308 

—  and  blood  diseases,  298 

— -causes  of,  See  Theories  of 

—  cessation  of,  at  menopause,  131 

— 'Character  of,  associated  with  intermen- 
strual pain,  226 

—  and    chlorosis,    characteristics   of    diseasCi 

298 

effect  of  chlorosis  on  menstruation,  299 

• — ■  amenorrhea,  299 

—  — ■ — •  dysmenorrhea,  300 
'menorrhagia,  300 

— •  —  effect  of  menstruation  on  chlorosis,  300 
harmfulness  of  emmenagogues  in  treat- 
ment of,  300 

treatment  of  menstrual  disorders  of  the 

disease,  300 

—  and  cholelithiasis,  304 

—  clinical  characteristics  of,  81 

effect  on  blood  pressure,  86,  87 

effect  on  body  temperature,  85,  86 


346 


INDEX. 


Menstruation  —  Continued 

effect  on  pulse  rate,  86,  ?>7 

knee  jerk,  88 

' and  the  "menstrual  wave"  theory,  85 

muscle  power,  86,  88 

pain  as  a  symptom,  81 

sexual,  84 

statistics   of  character  and   severity   of 

subjective  symptoms,  83 
various,  83 

—  and  coitus,  superstitions  regarding,  2,  5 

—  comparison  of  corpus  luteum  of,  and  cor- 

pus luteum  of  pregnancy,  55 

—  and  conception,  superstitions  regarding,  7 

—  and    dermatoses,    See    Menstrual    Derma- 

toses 

—  and  diabetes,  302 

—  discharge.  See  Menstrual  Discharge 

—  and  diseases,  288 

—  distinction  between  amenorrhea,   retention 

of   menses   and   suppression   of   menses, 
167 

—  duration  of  periods,  90 

—  and  ecchymoses,  309 

—  effect  of,  on  blood  picture,  92 

on  blood  pressure,  86,  87 

on  body  temperature,  85,  86 

on  knee  jerk,  88 

on  muscle  power,  86,  88 

on  pulse  rate,  86,  87 

—  and   the  endocrine  glands,   characteristics 

of  the  endocrine  bodies,  269 

—  —  introductory,  269 
mammary,  282 

ovary,  castration  in  early  life,  effect  of, 

270 

as  an  endocrine  gland,  270 

menstruation      after       removal       of 

ovaries,  274 

part  played  by,  at  puberty  and  at  the 

menopause,  270 

surgical  menopause,  cause  of  symp- 
toms of,  272 

its  manifestations,  271 

transplantation,  272 

pancreas,  283 

—  pineal  body,  general,  280 

— • feeding  experiments,  281 

results  of  extirpation,  281 

so-called  pineal  syndrome,  281 

— ■  —  pituitary  body,  adiposogenital  dystrophy, 
277 

■ — 'general,  277 

influence  of,  on  body  growth,  278 

— • 'pituitary  hypertrophy  after  castra- 
tion, 278 

■  —  in  pregnancy,  278 

principal  endocrin  glands  and  their  im- 
portance to  the  body  economy,  269 

suprarenal  bodies,  difference  in  function 

between  cortex  and  medulla,  279 


Menstruation  —  Continued 

effects    on    reproductive    system    of 

hypertrophy  without  tumors,  280 
— • effects  of  tumors  of,  on  reproductive 

system,  279 
hypoplasia    of,    associated    with    re- 

tarted  sexual  development,  280 
— • relation    between    function    of,    and 

gonads,  279 

—  —  thymus,  281 

thyroid,   evidences   of   relation  between 

thyroid  and  gonads,  276 

menstrual  disorders  accompanying  thy- 
roid diseases,  276 

— •  and  epilepsy,  305 

— •  and  erysipelas,  309 

—  and  erythema,  308 

—  and  erythema  and  nodosum,  309 

—  euphemisms  of,  6 

—  excessive,     with     hyperplasia     of     endo- 

metrium in  very  young  patients,  247 
— •  —  in  influenza,  298 

in  pneumonia,  297 

— ■  ferment  theory  of,  9 

—  and    gastro-intestinal    diseases,    effect    of 

menstruation    on    secretory    and    motor 
functions  of  the  stomach,  303 
reciprocal  relations  of,  303 

—  and  Graves'  disease,  relation  of,  301 
— 'and  hemophilia,  301 

—  and  herpes,  308 

—  histological  reaction  of  hypoplastic  uterus 

to,  195 

—  historical  sketch  of  older  theories  of,  67 

—  history  of,  1 
ancient,  1 

abhorrence    for    menstruating    women, 

1,  2 
— ■  —  Aristotle's  views,  4 
— ■  —  biblical  references,  2 

^beginning  of  really  scientific  study  of,  9 

— • — ^  coitus  during  period,  2 

—  —  customs      of      aborigines      of      South 

America,  4 

African  customs  in  regard  to,  3 

customs  among  modern  Greeks,  2 

— ■  —  Hottentot  customs,  4 

'Indian  customs,  3 

Jewish  custom,  3 

—  —  customs     of     savages     and     barbarous 

tribes,  3 

customs  of  South  Sea  Islanders,  4 

decree  of  the  Council  of  Nice,  3 

'earliest  ideas,  1 

— ' — ferment  theory,  9 

— '  —  John  Freind's  views  on,  4 

—  —  German  views  on,  3 
— ■  —  Greek  name  for,  1 

■ ^  Hippocrates*  views  on,  4 

— • — -as  an  influence  against  sickness,  6 
modern,  5 


INDEX. 


347 


Menstruation  —  Continued 

'among  medical  profession,  5 

plethora  theory  of  Galen,  9 

Pliny,  1 

'Supposed  causes,  8,  9 

-supposed  effects  of,  on  dogs,  1 

— • on  insect  life,  1,  2 

on  meat  salted  during  period,  5 

■  —  menstrual  blood,  1 

'on  milk  and  milk  supply,  4 

'On  mirrors,  4 

'On  sugar,  5 

on  vegetation,  2,  3 

views  as  to  pernicious  quality  of  men- 
strual blood,  1,  2,  3,  4 

views  against  pernicious  quality  of  men- 
strual blood,  4 

—  and  hysteria,  306 

—  and  infectious  diseases,  298 

— •  influence  of,  on  blood  picture,  92 

•  —  erythrocytes,  92 

hemoglobin,  92 

leukocytes,  93 

— ■ sugar  content  of  blood,  94 

on  breast  milk,  164 

on  fever,  296 

—  and  influenza,  298 
— •  and  insanity,  307 

—  interval  between  periods,  89 

—  and  intoxications,  chronic,  307 

—  and  joint  diseases,  acute  articular  rheuma- 

tism, 304 
"menstrual  arthritis,"  304 

—  and   lactation,    amenorrhea    during   lacta- 

tion, 162 

cause   of   amenorrhea   during  lactation, 

163 

•  Essen-Moller's  statistics,  162 

influence    of    menstruation    on    breast 

milk,  164 

ovulation  during  lactation,  164 

reappearance    of    menstruation    before 

end  of  lactation,  162 

Remfry's  statistics,  162 

Reichert  theory  that  ovulation  and  fer- 
tilization precede  menstruation,  155 

statistics  bearing  on,  162 

statistics  on,  reasons  for  discrepancy  in, 

163 

Thiemich's  statistics  on,  162 

—  and  leukemia,  300 

—  and  the  "libido  sexualis,"  84 

—  and  liver  diseases,  choleliathiasis,  304 

menstrual  hyperemia  of  the  liver,  303 

menstrual    jaundice    (icterus    menstru- 

alic),  303 

—  moderate     discomfort     of,     differentiated 

from  dysmenorrhea,  190 

— -  and  myxedema,  302 

I —  nasal  bleeding  and  sensitiveness  associ- 
ated with,  218 


Menstruation  —  Continued 

— -and  nervous  and  mental  diseases,  epilepsy, 

305 
— • — ■hysteria,  306 

—  — •  insanity,  307 

—  ^intoxications,  chronic,  307 

—  nervous    and    psychical    disturbances    of, 

treated  by  radium  and  X-ray,  333 
^and  non-conception,  older  theory  of,  69 
— ■objective  symptoms  of,  94 
— • — ■menstrual  discharge,  94 

—  —  non-coagulability  of  menstrual  blood,  95 
— •  occurrence  of,  in  pneumonia,  297 

— -occurrence   of   ovulation  before  onset  of, 

152 
— -onset   of,   at   period   some   multiple    of    9 

months,  115 

■  at  puberty,  100 

age,  102 

— ■  —  influence  of  individual  factors,  104 

— ■ -influence  on,  of  race,  climate,  etc., 

102 
as  only  one  of  the  manifestations  of, 

101 
— ■  and    the    ovary,    castration    in    early    life, 

effect  of,  270 
— ■ — -menstruation     after     removal     of     the 

ovaries,  274 
— -  —  ovary  as  an  endocrine  gland,  270 
part  played  by  ovary  at  puberty  and  at 

the  menopause,  270 
surgical  menopause,  cause  of  symptoms 

of,  272 
— ■ — ■  —  its  manifestations,  271 
transplantation  of  the  ovaries,  272 

—  — ■  —  general  results,  272 
procedures,  272 

^and  ovulation,  clinical  observations  on,  152 

relation    of    estrus    and    ovulation    in 

lower  animals,  150 

— ■  —  evidence  from  embryological  studies, 
155 

evidence  from  operative  and  postmor- 
tem findings,  154 

-general  considerations,  152 

— -  —  general  histological  studies  on,  155 

— -  —  histological  studies  on,  155 

—  —  histological  studies  of  ovary,  158 

—  — -historical,  150 

— -  —  ovulation  during  "dodging  period"  of 
puberty  and  menopause,  152 

—  —  ovulation  during  lactation,  153 

—  — 'Ovulation  after  menopause,  153 

ovulation  during  pathological  amenor- 
rhea, 153 

—  — 'Ovulation  during  pregnancy,  153 
— '^ovulation  before  puberty,  152 

— occurring       during       intermenstrual 

period,  at  any  time.  Teacher's  table,  157 

—  — fifteenth        to        tvi^entieth        day, 

Fraenkel's  theory,  158 


348 


INDEX. 


Menstruation. —  Continued 

first  half  of,  author's  theory-,  159 

fourteenth       to       sixteenth       day, 

Schroder's  theor>',  159 
. .  —  nineteenth     day,     about,     Miller's 

theor}',  159 
occurring  in  either  postmenstrual  or 

interval  periods  of  menstrual  cycle,  first 

and    fourteenth    day,    Meyer    and    Ruge 

theor>%  158 
preceding  menstruation,  Reichert-His 

theory,  155 
succeeding     menstruation,     Ahlfeld's 

table,  156 

Mall's  theory,  156 

summary  of  clinical  evidence,  155 

—  pain  as  a  symptom  of,  findings  of  Chis- 

holm,  81 

. findings  of  Dr.  Mary  A.  Hodge,  82 

findings  of  Marie  Tobler,  82 

location  of,  82 

—  periodicity  of  menstrual  flow,  88 

—  and  pernicious  anemia,  300 

—  phenomenon  of,  analogy  between  heat  or 

estrus  and,  10 

—  and    pneumonia,    effect   of   pneumonia   on 

menstruation,  297 
occurrence  of  menstruation,  297 

—  physiology  of,  comparative,  10 

and    comparative   study   of    lower    ani- 
mals, 10 
. —  plethora  theory  of,  of  Galen,  9 

—  precocious,  age  observed  at,  113,  114 
associated    with    tumors    of    generative 

glands,  117 
associated  with  tumors  of  pineal  gland, 

118 

cause  of,  117 

clinical  manifestations  of,  115 

what  constitutes,  113 

diagnosis  of,  118 

diff'erentiated        from        non-menstrual 

hemorrhage  of  the  newborn,  118,  121 

—  — from  precipitation  of  urates  from  urine 

of  infants,  118 

. early  manifestations  of  premature   de- 
velopment, 113 

frequency  of,  113 

pregnancy  in  cases  of,  117 

psychic  development  in,  117 

subsequent  history  of  patients  with,  116 

■ treatment  of,  119 

types  of,  115 

—  and  pregnancy,  superstitions  regarding,  2 

—  process  of,  congestion  and  increased  thick- 

ness of  endometrium,  25 
__  —  developmental  cycle  in  the  endometrium, 

28 

epilhelial  changes  during,  31 

glandular  changes  during,  33 

—  — interval  stage  of  endometrium,  29 


Menstruation  —  Continued 

pelvic  hyperemia,  25 

'postmenstrual  stage  of  endometrium,  29 

—  —  menstrual  stage  of  endometrium,  30 

— •  —  premenstrual  stage  of  endometrium,  29 

proliferative  stage  of  endometrium,  31 

— • — 'question  of  loss  of  uterine  mucosa  in, 36 
— -process  of,  stages,  25 

— • desquamation    and    degeneration    of 

endometrium,  31 

external  hemorrhage,  25 

— • postmenstrual  regeneration,  25 

— • — •  —  premenstrual  congestion,  25 

—  —  secretory  stage  of  endometrium,  31 

—  —  stromal  changes  during,  34 
— ■  —  vascular  changes,  35 

—  pseudo,  274 

— •  question  of  participation  of  fallopian  tubes 

in,  20 
— ■  —  clinical  evidence,  20 

—  —  histological  evidence,  21 

— ■  after  removal  of  ovaries,  accessory  ovarian 

tissue,  275 
— ■  —  pseudomenstruation,  274 
— ■  —  removal  apparently  complete,  274 
— • — supernumerary  ovaries,  275 
— ■ — 'theories  of,  274 

—  retention  of,  167 
— •  —  diagnosis  of,  176 

—  as  a  secretory  process,  older  theory  of,  70 
— •  and  sexual  appetite,  older  theory  of,  69 

—  size  of  cervical  canal  during,  20 
— •  and  skin  pigmentation,  309 

— ■  and  stomach  disorders,  303 

—  subjective  symptoms  of,  blood  picture,  92 

—  —  blood  pressure,  86,  87 
— •  —  body  temperature,  85,  86 
— • — 'knee  jerk,  88 

and  the  "menstrual  wave"  theory,  85 

—  —  muscle  power,  86,  88 
-pain,  81 

— •  —  periodicity  of  menstrual  flow,  88 

■  pulse  rate,  86,  87 

— •  —  sexual,  84 

statistics  of  character  and  severity  of, 

83 

—  —  table  of  Marie  Tobler,  84 
— •  —  various,  83 

—  superstitions  of,  1 

— • — -among  African  tribes,  3,  4 
— ■ — among  ancient  Persians,  2,  3 
-among  German  peasants,  3 

—  — -among  Hottentots,  4 

—  —  among  the  Indians,  3 
among  Jewesses,  3 

—  — -among  medical  profession,  5 

-among  modern  Greeks,  2 

ancient,  1 

— ■ — -association    between    woman    and    the 
serpent,  6 

—  —  biblical,  2 


INDEX. 


349 


Menstruation  —  Continued 

■ as  a  fatal  poison,  Plinj%  1 

■ as  ail  inllucnce  against  sickness,  6 

lunar  intluences,  8 

—  —  magical  potency,  7 
. modern,  5 

— ■ ^  among  medical  profession,  5 

regarding  coitus,  2,  5 

regarding  conception,  7 

-^ regarding  dogs,  1 

regarding  horses,  2 

•  regarding  insects,  1,  2,  5 

regarding  meats,  5 

—  —  regarding  milk  and  milk  supply,  4,  5 

—  — •  regarding  mirrors,  4 

regarding  musical  instruments,  5 

— • — .regarding  opium,  5 

regarding  pregnancy,  2 

regarding  sugar,  5 

regarding  vegetation,  1,  2 

regarding  wine,  3 

—  suppression  of,  167 

due  to  chilling  of  body,  symptoms  of, 

176 

—  and  syphilis,  297 

'amenorrhea,  297 

— •  —  menorrhagia,  297 

—  theories  of,  earliest,  67 

factors  considered  responsible  for,  67 

ferment  theory,  67 

"Fervor  uterinus"  of  Democritus,  67 

•  —  influence  of  vertical  position,  68 

lunar  influence,  8,  67 

—  r ^^  menstrual  center  theory,  70 

Pfliiger's,  68 

plethora  theory  of  Galen,  67 

■ — 'as  a  result  of  non-conception,  69 

as  result  of  sexual  appetite,  69 

■  —  as  a  true  secretory  process,  70 

—  —  —  "tubal  nerve"  of  Tait,  68 

■ as  an  "unnatural  process,"  69 

modern,  of  Aschner,  75 

•  —  conclusions  regarding,  77 

•  —  corpus  luteum  theory  of  Fraenkel,  74 

■—  —  conclusions  regarding  77 

• — •  —  histological    confirmation    of,    76 

• — ■  —  views  opposing,  74,  75 

essential  feature  of,  71 

of  Halban,  75 

influence  of  endocrine  glands   other 

than  ovary,  78 

local  factor  in  endometrium,  78 

—  of  Loeb,  75 

— of  Marshall,  74 

• — ■ovarian  constituent  concerned,  74 

• ■  —  ovarian    influence     exerted    through 

blood  stream,  and  not  by  nerves,  73 
,^-  — —  ovarj'  as  underlying  cause,  73 

• — ■  —  injection  experiments,  77 

— steps  leading  to,  70 

of  Theilhaber,  74 


Menstruation  —  Continued 

— • vascular  and  vasomotor  factors,  78 

— - — -older,  historical  sketch  of,  67 

— ■ — 'Steps  leading  to  modern  conception  of, 

70 
— ^and  thyroid  disease,  276,  301,  321 
— ■  time  relation  between,  and  histological  ap- 
pearance  of   endometrium  and  stage  of 
development  of  corpus  luteum,  54 

—  and    tuberculosis,    general    considerations, 

288 

influence  of  menstruation  on  tuber- 
culosis, general,  292 

historical,  292 

• — 'intermenstrual  iever,  293 

postmenstrual  fever,  293 

— ■ — ■  —  premenstrual  fever  on  consumptives, 
292 

on   subjective    symptoms   of    disease, 

293 

'influence  of  tuberculosis  on  menstru- 
ation, 288 

age  of  patient,  289 

'amenorrhea      more      common      than 

menorrhagia,  288 

— ' dysmenorrhea,  291 

explanation  of  amenorrhea  in  tuber- 
culosis, 290 

menorrhagia,  290 

menstrual    disturbances    not    usually 

dependent  on  local  lesions  in  pelvis,  289 

practical  importance   of   amenorrhea 

in  tuberculosis,  290 

stage  of  the  disease,  289 

relation  of,  172 

—  and  typhoid  fever,   influence   of  menstru- 

ation on  typhoid,  fever,  296 

general  considerations,  295 

influence  on  treatment  for,  296 

relation  of  menstrual  date  to  time  of 

onset  of  disease,  295 

^  influence   of    typhoid   on    menstruation, 

general  considerations,  294 

hematometra,  295 

menstruation  usually  absent  or  di- 
minished, 294 

—  ^-  —  peri-uterine  hematocele,  295 

■  —  uterine  bleeding  in  hemorrhagic  type 

of  typhoid,  294,  295 
— ' variations  in,  294 

—  as   an  "unnatural  process,"   older   theory 

of,  69 
— '  and  urticaria,  308  '      ^ 

—  vascular  and  vasomotor  factors  in,  78 
— 'Vicarious,  See  Vicarious  Menstruation 
Mental  disorders,  amenorrhea  due  to,  173 

—  of    menopause.    See    Menopause,    Psycho- 

pathies of 

IMental  and  nervous  diseases,  and  menstru- 
ation, See  Mens-truation  and 

Metestrum,  14  —  - 


350 


INDEX. 


Metrorrhagia,  causes  of,  discussed  with  those 
of  menorrhagia,  229 

—  in  influenza,  298 

—  in  melancholia,  307 

— ^and  the  menopause,  131 

—  and  thjToid  disease,  276 

"  Metrorrhagia  myopathica  "  of  Anspach,  238 
Meyer  and  Ruge  theory  of  relation  of  men- 
struation and  ovulation,  158 
Miller's  theory  of  relation  of  ovulation  and 

menstruation,  158 
Monestrous  animals,  14 

Morphin,  in  treatment  of  dysmenorrhea,  204 
]\Iorphinism,  amenorrhea  with,  307 
Motor  functions  of  stomach,  e:ect  of  men- 
struation on,  303 
IVIucosa,  uterine,  question  of  loss  of,  in  men- 
struation, 36 
Mukilocular  cysts,   uterine  hemorrhage   due 

to,  243 
Muscle  power,  effect  on,  of  menstruation,  88 
]\Iuscular  insufficiency  of  the  uterus,  uterine 

hemorrhage  due  to,  236 
Myoma,  sloughing,  submucous,  distinguished 
from  membranous  dysmenorrhea,  217 

—  of  uterus,  dysmenorrhea  due  to,  202 

—  uterine  hemorrhage  due  to,  240 

treatment  of,  by  X-ray,  327 

Myxedema,  effect  of,  on  menstruation,  302 

Navel-Veit  theory  of  gynatresia,  183 

Nasal     dysmenorrhea,     See     Dysmenorrhea, 

nasal 
Nasal  mucous  membrane,  source  of  vicarious 

menstruation,  261 
Nephritis,  amenorrhea  due  to,  173 
Nervous  causes  of  uterine  hemorrhage,  251 
Nervous  disorders,  amenorrhea  due  to,   173 

—  occurring  during  menstrual  periods,  treat- 

ment of  by  radium  and  X-ray,  333 

Nervous  symptoms,  at  menopause,  133 

treatment  of,  140 

Nervous  and  mental  diseases,  and  menstru- 
ation. See  Menstruation  and 

Neuralgic  dysmenorrhea,  199 

Neurasthenia,  causing  dysmenorrhea,  pri- 
mary, 198 

secondary,  198 

Neurasthenic  dysmenorrhea,  198 

Nevi,  hemorrhage  from,  in  vicarious  men- 
struation, 264 

Nipple,  hemorrhage  from,  in  vicarious  men- 
struation, 263 

Non-menstrual  genital  hemorrhage  of  the 
newborn,  accompanying  symptoms,  122 

—  amount  and  character  of  bleeding,  122 

—  differentiated    from    precocious    menstru- 

ation, 118,  121 

—  duration  of  bleeding,  122 
• — etiology  of,  122 


Non-menstrual   genital    hemorrhage    of    the 
newborn  —  Continued 

—  frequency  of,  121 
— 'Prognosis  of,  122 

—  time  of  occurrence  of  bleeding,  121 

—  treatment  of,  123 

Neuroses,  associated  with  amenorrhea,  175 

—  dysmenorrhea  due  to,  196 
Nose,  "genital  spots"  in,  218 

—  and  generative  organs,  theories  of  nature 

of  relation  between,  218 
Numbness,  as  symptom  of  menopause,  133 

Obesity,  amenorrhea  due  to,  174 

—  influence  of,  on  menopause,  128 
Obstruction    of    uterine    gland,    mechanical, 

causing  dysmenorrhea,  192 

Ocular  conditions,  associated  with  amenor- 
rhea, 175 

Oophorectomy,  in  early  life,  270 

—  effect    of,     differentiated     from    the    ray 

menopause,  330 

—  menstruation  after,  274 

— ■  —  when   removal   is   apparently   complete, 

274 
pseudomenstruation,  274 

—  — theories  of,  274 

—  pituitary  hypertrophy  after,  278 

—  results  of,  271- 
'their  cause,  272 

Open  air  recreation  for  amenorrhea,  177 
Opium,  in  treatment  of  dysmenorrhea,  204 
Organotherapy    of    menstrual    disorders,    in 
amenorrhea,     associated    with    adiposo- 
genital dystrophy,  318 

functional,  of  later  life,  318 

of  puberty,  317 

—  in  dysmenorrhea,  324 

—  introductory,  314 

—  organ  extracts  used,  extract  of  ovary  or 

corpus  luteum,  316 

general  considerations,  314 

— '  —  pituitary  extract,  315 
thyrOid  extract,  315 

—  in    ut'erine     hemorrhage,     functional,     of 

puberty  and  menopause,  322  . 
— '  —  of  hypothyroidism,  321 

—  in  vasomotor  symptoms  of  menopause,  323 
Ovarian   element   concerned   in   hyperplasia, 

250 

Ovarian  extract,  in  treatment  of  menstrual 
disorders,  316 

— ' — -amenorrhea,  associated  with  adiposo- 
genital dystrophy,  319 

'amenorrhea  of  puberty,  318 

'dysmenorrhea,  324 

menorrhagia  of  menopause,  323 

— '  —  of  vasomotor  symptoms  of  menopause, 
324 

"  Ovarian  residue,"  employment  of,  in  or- 
ganotherapy, 317 


INDEX. 


351 


Ovarian  tissue,  accessory,  275 

—  avoidance  of  complete  removal  of,  in  sur- 

gery, 129 

—  secreting',   destruction   or  loss  of   function 

of,  inducing  amenorrhea,  170 
Ovaries,    anatomical   changes   in,   after   radi- 
ation, 329 

—  autotransplantation  of,  272 
operative  lechnic,  273 

—  castration,    during    child    bearing    age    in 

woman,  cause  of  symptoms  of,  272 

effects  of,  271 

in  early  life,  270 

menstruation  after,  274 

—  changes  in,  at  menopause,  137 
• at  puberty,  101 

• —  congenital  absence  of,  amenorrhea  due  to, 

168 
— •  menstruation  after  removal  of,  274 

accessory  ovarian  tissue,  275 

when  apparently  complete,  274 

pseudomenstruation,  274 

supernumerary  ovaries,  275 

■ theories  of,  274 

—  relation  between  pancreas  and,  283 

— '  removal  of,  hvpertrophy  of  pituitary  gland 

after,  278 
— •  supernumeran,',  275 

—  transplantation  of,  272 
autotransplantation,  272 

autotransplantation,     operative    technic, 

273 
— •  —  general  results,  272 
— • — 'heterotransplantation,  272 

homotransplantation,  272 

present  status  of,  273 

—  corpus    luteum,    chronological    relation    of 

cjxle  of,   to  menstrual  and  endometrial 
cycles,  52 

—  —  comparison  of,  in  menstruation  and  in 

pregnancy,  55 

—  —  general, 

life  C3'cle  of,  45 

modern  conception  of,  44 

— • — -older  views  as  to,  43 
origin  of  lutein  cells,  58 

—  as  an  endocrin  gland,  270 

—  follicles  of,  Graafian,  42 
primordial,  42 

— •  general   importance  of,  in  body  economy, 

270 
■ — gross  anatomy  of,  40 

—  histological  studies  of,  158 

—  histology  of,  41 

— •  hj^persecretion  of,  uterine  hemorrhage  due 
to,  244 

—  important  constituents  of,  41 
corpus  luteum,  43 

follicles,  42 

interstitial  cells,  60 


Ovaries  —  Continued 

—  importance  of,  in  development  of  secondary 

sexual  characteristics,  105,  106 

—  interstitial  cells  of,  general,  60 

—  —  human,  61 

— ■ — ^  in  lower  animals,  61 

—  —  origin  of,  from  walls  of  atretic  follicle, 

63 

—  menstrual  cj^clic  changes  in,  40 

^part    played    by,    at    puberty    and    at    the 
menopause,  270 

—  as  responsible  for  vicarious  menstruation, 

266 
— ■  stroma  of,  41 

— •  subservience  of  endometrium  to,  249 
^tumors  of,  uterine  hemorrhage  due  to,  243 
— ^as  underlying  cause  of  menstruation,  73 
— •  —  Aschner's  theory  of,  75 

constituent  of  ovary  concerned  with,  74 

corpus  luteum  theory  of  Fraenkel,  74 

— • — •  —  conclusions   regarding,  11 

—  — ■  —  histological  confirmation  of,  76 
— ■  —  Halban's  theory,  75 

influence  exerted  through  blood  stream 

and  not  by  nerves,  IZ 
— •  —  injection   experiments,  77 
— •  —  Loeb's  theorj^,  75 
— '^JMarshaH's  theory  of,  74 
Ovulation,  appearance  of,  at  puberty,  101 

—  Fraenkel's  date  of,  158 

—  during  "dodging  period"  of  puberty  and 

menopause,  152 

—  during  lactation,  153,  164 
— 'after  menopause,  153 

—  and   menstruation.    See   Menstruation   and 

Ovulation 
— ■  during  pathological  amenorrhea,  153 
— •  during  pregnancy,  153 

—  before  puberty,  152 

— -relation  of  estrus  and,  in  lower  animals, 

150 
Ovum,  structure  of,  42 

Pain,     intermenstrual.     See     Intermenstrual 

Pain 
— -in  normal  menstruation,  findings  of  Chis- 

holm,  81 

^  findings  of  Dr.  Mary  A.  Hodge,  82 

'location  of,  82 

findings  of  Marie  Tobler,  82,  84 

Pancreas,  relation  of  ovaries  to,  283 
Papillomatous  cj'sts,  uterine  hemorrhage  due 

to,  243 
"  Paralutein  "  cells,  50 
Paranoia  associated  with  menopause,  148 
Pelvic  lesions,  associated  with  intermenstrual 

pain,  226 

—  dysmenorrhea  due  to,  200 

—  influence  of,  on  menopause,  128 
— '  thyroid  disease  as  a  result  of,  276 
Pelvic  hyperemia  in  menstruation,  25 


352 


INDEX. 


Pelvic  organs,  amenorrhea  due  to,  acquired 
pathological  conditions  of,  169 

—  inflammatory    disease    of,     dj'smenorrliea 

due  to,  201 

Pelvis,  menstrual  disturbances  not  usually- 
dependent  on  local  lesions  in,  289 

"Period  of  rest,"  25 

Periodic  sex  activity,  in  lower  animals,  11 

■ — 'Conditions  influencing,  11 

—  discharge  from  generative  tract,  12 

—  earliest  manifestations  of,  10 

—  seasons  of,  See  Sexual  Seasons 
Periodic  sexual  phenomena  in  lower  animals, 

analog}^    between    estrus    and    menstru- 
ation, 16 

—  and   comparative  physiology   of   menstru- 

ation, 10 
' —  discharge  from  generative  tract,  12 

—  earliest  manifestations  of  activity,  10 
— 'estrus,  11,  13 

■ — general  considerations,  10 

—  "heat"  or  estrus,  11 

—  proestrum,  12 

■ duration  of,  13 

• internal  phenomena  associated  with,  13 

—  swelling  and  congestion  of  external  geni- 

talia, 12 
Periodicity  of  menstrual  flow,  88 

—  inter\^al  between,  89 

Peri-uterine  hematocele,  in  typhoid  fever,  295 

Perivitelline  space,  43 

Pernicious  anemia,  effect  of,  on  menstruation, 

300 
Peters  ovum,  age  of,  156 
Pfliiger's  theory  of  menstruation,  68 
Pigmentation,  menstrual,  310 

—  relation    of,    to    reproductive    function    in 

lower  animals,  11 
Pineal  body,  feeding  experiments,  281 

—  relation  of,  to  sexual  apparatus,  280 

—  results  of  extirpation,  281 

—  tumors  of,  associated  with  precocious  men- 

struation, 118 

Pineal  syndrome,  so-called,  280 

Pituitary  body,  hypertrophy  ©f,  after  castra- 
tion, 278 

—  hypertrophy  of,  in  pregnancy,  278 

—  influence  of,  on  body  growth,  278 

—  relation  of,  to  generative  glands,  277 

adiposogenital  dystrophy,  277 

Pituitary  disease,  amenorrhea  due  to,  174 
Pituitary  extract,   in  treatment  of   menstrual 

disorders,  315 

— •  —  amenorrhea,  associated  with  adiposo- 
genital dystrophy,  319 

dysmenorrhea,  324 

Plastic  operations  on  cervix,  in  treatment  of 
dysmenorrhea,  211 

Plethora  theory  of  menstruation  of  Galen,  67 

—  and  factors   influencing  age  for  onset  of 

menstruation,  105 


Pneumonia,    occurrence   of    menstruation   in, 

297 
— ■  effect  of,  on  menstruation,  297 
Polyestrous  animals,  14 
Polj'pi,  cervical,  uterine  hemorrhage  due  to, 

231 
— 'Corporeal,  uterine  hemorrhage  due  to,  232 
— '  uterine  hemorrhage  due  to,  231 
Postmenstrual  fever,  in  tuberculosis,  293 
Postmenstrual  regeneration,  25 
Postmenstrual  stage  in  endometrium,  29,  32 
Prepubescence,  101 
Pregnancy,  after  the  menopause,  153 
— 'amenorrhea  during,  171 
— 'in  cases  of  precocious  menstruation,  117 

—  — 'differentiated  from  menopause,  138 

—  comparison  of  corpus  luteum  of,  and  cor- 

pus luteum  of  menstruation,  55 
— '  during  "  dodging  period  "  of  puberty  and 

the  menopause,  152 
— •  ectopic,  uterine  hemorrhage  due  to,  242 

—  hypertrophy  of  pituitary  body  in,  278 

—  and    menstruation,     superstitions     regard- 

ing, 2 
^occurrence  of,  during  lactation,  153 
'during  pathological  amenorrhea,  153 

—  — 'before  puberty,  152 

—  ovulation  during,  153 

— '  during    pathological     amenorrhea     associ- 
ated with  adiposigenital  dystrophy,  154 

—  spurious,   and  amenorrhea  of  menopause, 

139 
— -vicarious  menstruation  during,  265 
Precipitation  of   urates   from   urine   of  new 
■born,  differentiated  from  precocious  men- 
struation, 118 
Premature  development,  symptoms  of,  mam- 
mary hypertrophy,  116 

precocious  menstruation,  116 

Premenstrual  congestion,  stage  of,  25 
Premenstrual  fever,  in  tuberculosis,  292 
Premenstrual   hypertrophy   of    endometrium, 
degree     of,     proportionate     to     clinical 
severity  of  menstrual  bleeding,  195 
Premenstrual  stage  in  endometrium,  29,  32 
Prescriptions,  Goodell's  pill,  containing  aloes, 

in  treatment  of  amenorrhea,  180 
— •  Herman's,    for  treatment   of   amenorrhea, 

179 
— ■  of  iron  and  arsenic  in  treatment  of  amen- 
orrhea, author's,  17'8 

—  Kelly's,   of    iron,   arsenic    and   manganese, 

for  treatment  of  amenorrhea,  180 
— - — for  treatment   of   local   disturbances   of 

menopause,   141 
— 'in  treatment  of  dysmenorrhea,  204 
Proestrum,  12 
— -duration  of,  12 

— 'internal  phenomena  associated  with,  13 
— '  stages  associated  with,  period  of  degenera- 
tion, 13 


INDEX. 


353 


Proestrum  —  Continued 

period  of  growth,  13 

recuperative,  13 

resting,  13 

Proliferation  of  corpus  lutcum,  45 

Protoplasm  of  the  ovum,  43 

Pruritis,  as  symptom  of  menopause,  133 

—  senile,  of  menopause,  treatment  of,  141 
Pscudocyesis,  and  amenorrhea  of  menopause, 

139 

—  difficulty  of  diagnosis  of  true  amenorrhea 

and,  177 

Pseudo-erysipelas,  menstrual,  309 

Pseudomenstruation,  274 

Psychic  development  in  precocious  menstru- 
ation, 117 

Psychic  disturbances,  amenorrhea  due  to,  171 

—  occurring  during  menstrual  periods,  treat- 

ment of,  by  radium  and  X-ray,  333 

Psychic  symptoms  of  menopause,  133 

Psychical  changes,  at  puberty,  101 

Psychopathies  of  the  menopause,  See  Meno- 
pause, psychopathies  of 

Psychoses,   associated  with  amenorrhea,   175 

Pubertas  precox,  115 

Puberty,  acne  at,  309 

—  adolescent  group,  101 

—  amenorrhea    of,    organotherapy    in    treat- 

ment of,  317 
■ —  cause  of,  105 

—  changes  in  reproductive  organs  at,  100 

—  "  dodging  period  "  of,  ametiorrhea  during, 

170 

—  general  body  changes  at,  100 

—  general  consideration  of,  100 

—  hemorrhage  of,  246 

—  hygiene  of,  bathing,  111 

care  of  the  bowels,  112 

clothing,  110 

diet,  111 

general,  112 

— ■  —  instruction  in  sex  hygiene,  108 
— •  —  recreation  and  rest,  110 

role  of  the  mother,  108 

school  life,  109 

— •  —  working  conditions,  109 

—  menorrhagia  of,  thyroid  extract  in  treat- 

ment of,  322 

—  menstruation   only   one   of   rr.aaifestations 

of,  101 

—  and  the  onset  of  menstruation,  100,  101 

as  only  one  of  the  manifestations,  101 

age,  102 

influence  on  of  climate,  race,  etc.,  102 

influence  of  individual  factors,  104 

—  ovulation  before,  152 

—  ovulation  during  "  dodging  period  "  of,  152 
— ^part  played  by  ovary  at,  270 

—  physiological  changes  at,  101 

—  precocious,  113,  115 

—  prepubescent  group,  101 


Puberty  —  Continued 

—  psychical  changes  at,  101 

—  pubescent  group,  101 
Pubescence,  101 

Puerperal  infection  or  lacerations,  gynatresia 

due  to,  184 
Pulse  rate,  effect  of  menstruation  on,  86,  87 
Pyramidon,    iu    treatment    of    dysmenorrhea, 

204 

Racial  influences,  on  menopause,  128 
Radium,   in  treatment  of   local   disturbances 

of  menopause,  141 
Radium   and  X-ray  treatment  of   menstrual 

disorders,    anatomical    changes    observed 

in  the  ovaries  and  uterus  after  radiation, 

329 

—  cases   with  abnormality  of   the  menstrual 

flow,  331 

—  cases  characterized  by  nervous  or  psychical 

disturbances  present  principally  or  solely 
during  menstrual  periods,  333 

—  cases    characterized    by    painful    menstru- 

ation, 332 
— ■  classification    of    dysmenorrhea    from    the 
ray  therapy  standpoint,  331 

—  comparative  usage  of,  328 

— •  factors  militating  against  use  of,  327 

—  history  of,  327 

—  inducement    of    complete   amenorrhea    by, 

327 

—  introduction  to,  327 

—  literature  on,  328 
— 'ray  menopause,  330 

— 'technic  of  radiation,  330 

— ^  uterine  fibroids,  328 

— •  for  uterine  hemorrhage  due  to  myomata, 
327 

Ray  menopause,  330 

Rales  of  tuberculosis,  influence  of  menstru- 
ation on,  293 

Recreation,  in  hygiene  of  puberty,  110 

Reichert  —  His  theory  of  relation  of  evula- 
tlon  and  menstruation,  155 

Reproductive  function,  in  lower  animals,  re- 
lation of  pigmentation  to,   11 

Reproductive  organs,  congenital  absence  or 
malformations  of,  amenorrhea  due  to, 
168 

— •hj'poplasia  of,  causing  d3rsmenorrhea,   193 

—  relation  of  pineal  body  to,  280 

— •  relation  between  suprarenal  bodies  and, 
279 

— •  relation  of  thymus  to,  281 

Rest,  in  hygiene  of  puberty,  110 

Rheumatism,  acute  articular,  and  menstrua- 
tion, 304 

Retained  menstrual  discharge,  in  gynatresia, 
chemical  composition  of,  187 

Retention  of  gestation  products.  See  Abor- 
tion, incomplete. 


354 


INDEX. 


Retention  of  menses,  diagnosis  of,  176 

—  distinction  between  amenorrliea,   suppres- 

sion of  menses  and,  167 

—  See  also  Gynatresia 
Retrodisplacement   of    uterus,    dysmenorrhea 

due  to,  201 
Retrogression  of  corpus  luteum,  stage  of,  50 
Rut,  12 

Sarcoma  of  the  uterus,  uterine  hemorrhage 
due  to,  239 

School  life,  in  hygiene  of  puberty,  109 

Schroeder's  theory  of  relation  of  ovulation 
and  menstruation,  159 

Secretory  functions  of  stomach,  efifect  of 
menstruation  on,  303 

Secretory  process,  menstruation  as,  70 

Senile  atresia,  g^^natresia  due  to,  185 

Senile  atrophy  of  menopause,  135 

Senile  pruritis  of  menopause,  treatment  of, 
141 

Senile  vulvitis  of  menopause,  135 

Senile  vulvovaginitis  of  menopause,  treat- 
ment of,  141 

Serum,  in  treatment  of  uterine  hemorrhage, 
256 

Sex  hygiene,  in  hygiene  of  puberty,  108 

—  instruction  in,  108 

Sexual  apparatus,  changes  in,  associated  with 
suprarenal  hyperplasia,  without  tumors, 
280 

—  relation  of  pineal  body  to,  280 

—  relation  to,  of  pituitary  body,  277 

—  relation    between    suprerenal    bodies    and, 

279 

—  relation  to,  of  thyroid  glands,  276 

—  retarded   development  of,   associated  with 

suprerenal  hypoplasia,  280 
Sexual   appetite,   increase  in,   at  menopause, 
134 

—  and  menstruation,  84 

—  older  theory  of  menstruation  as  due  to,  69 
Sexual  characteristics,  secondary,  105 

—  organs  influencing,  106 
Sexual  feasts,  15,  16 

Sexual  psychoses  of  menopause,  147 
Sexual  season  in  human  female,  special  and 
limited,  sexual  feasts  indication,  15 

—  transformation   of   one  type    of,    into   an- 

other, 15 
Sexual    season  in    lower   animals,    anestrous 

cycle,  12 

anestrous  period  or  anestrum,  14 

metestrous  period,  or  metestrum,  14 

period  of  estrus,  13 

proestrous  period,  or  procstrum,  12 

—  definition  of,  12 

—  di-estrous  cycle,  14 
duration  of,  15 

—  estrous  cycle,  14 

.—  "heat"  or  estrus,  11 


Sexual  season  in  lower  animals  —  Continued 

—  monestrous  animals,  14 
— 'polyestrous  animals,  14 

—  transformation   of   one   type   of,   into   an- 

other, 15 

Sexual  and  olfactory  apparatus,  theories  of 
nature  of  relation  between,  218 

Skin,  hemorrhage  from,  in  vicarious  men- 
struation, 263 

Skin  eruptions,  at  menopause,  134 

Social  condition,  influence  of,  on  menopause, 
128 

"  Spurious  pregnancy,"  and  amenorrhea  of 
menopause,  139 

Stem  pessaries,  dilatation  of  cervix,  continu- 
ous, by,  210 

"  Stephenson's  wave,"  85 

Sterility,  inducement  of,  by  radium  and 
X-ray,  327,  331,  332 

—  disorders  of,  and  menstruation,  303 

—  effect    of   menstruation   on    secretory   and 

motor  functions  of,  303 

—  source  of  hemorrhage,  in  vicarious  men- 

struation, 262 
Stroma  of  the  endometrium,  26 
— ■  changes  in,  during  menstrual  cycle,  34 
Stroma  of  the  ovary,  41 
"  Subepithelial  hematomata,"  25,  35  ' 
Subgranulosal  vascular  wreath,  47 
Sugar  content  of  blood,  influence  of  menstru- 
ation on,  94 
Sugar  in  urine,   examination   for,   at  meno- 
pause, 141 
Suprarenal  bodies,  difference  in  function  be- 
tween cortex  and  medulla,  279 
— 'effects  of  hyperplasia  of,  without  tumors, 
on  sexual  apparatus,  280 

—  effects  of  tumors  of,  on  reproductive  sys- 

tem, 279 

— 'hypoplasia  of,  associated  with  retarded 
sexual  development,  280 

— '  relation  between  function  of,  and  gonads, 
indications,  279 

Suprarenal  tumors,  effects  of,  on  reproduc- 
tive system,  279 

Suppression  of  menses,  distinction  between 
amenorrhea,  retention  of  menses,  and, 
167 

—  due  to  chilling  of  body,  symptoms  of,  176 
Surgical  menopause,  129 

Sweating,  at  menopause,  132 

— ■ — -treatment  of,  140 

Syphilis,  effect  of,  on  menstruation,  297 

•  menorrhagia,  297 

Tachycardia,  at  menopause,  133 
Tait's  "  tubal  nerve,"  68 

Teacher's  theory  of  relation  of  ovulation  and 
menstruation,  158 

—  table  showing,  157 

Teratomata,  uterine  hemorrhage  du     *o,  243 


INDEX. 


355 


Theca  folliculi,  42 

—  clianges    in,    in   stage   of  proIifcrali(jn    of 

corpus  luteum,  45 
Thcilhaber's  theory  of  menstruation,  74 
Throat,  sensory  neuroses  of,  at  menopause, 

147 
Thyroid  disease,  amenorrliea  due  to,  173 

—  as  a  result  of  pelvic  lesions,  276 
Thj-roid   gland,   menstrual   disorders   accom- 

panj'ing  disease  of,  276 

— •relation  between  gonads  and,  evidences  of, 
276 

Thymus  gland,  relation  of,  to  reproductive 
system,  281 

Thyroid  extract,  in  treatment  of  menstrual 
disorders,  315 

'amenorrhea,  associated  with  adiposo- 
genital dj'strophy,  320 

— ■  —  menorrhagia  of  hypothyroidism,  321 

menorrhagia  of  puberty,  322 

Tincture  of  chlorid,  in  treatment  of  amenor- 
rhea, 178 

Tingling,  as  s3'mptom  of  menopause,  133 

Tobler,  Marie  table  of,  on  subjective  symp- 
toms of  menstruation,  84 

Transplantation  of  ovaries,  See  Ovaries, 
transplantation  of 

Trauma,  gjmatresia  due  to,  185 

"  Tubal  nerve  "  of  Tait,  68 

Tuberculosis,  amenorrhea  due  to,  172 

— •  —  explanation  of,  290 

more  common  than  menorrhagia,  288 

•practical  importance  of,  290 

—  dysmenorrhea  due  to,  200,  291 

—  of  the  generative  organs,  uterine  hemor- 

rhage due  to,  242 

—  influence    of,     on    menstruation,     age    of 

patient,  289 

amenorrhea  more  common  than  menor- 
rhagia, 288 

— ■ — -dysmenorrhea,  291 

explanation  of  amenorrhea  in  tuber- 
culosis, 290 

' menorrhagia,  290 

menstrual  disturbances  not  usually  de- 
pendent on  local  lesions  in  pelvis,  289 

practical   importance  of   amenorrhea  in 

tuberculosis,  290 

stage  of  disease,  289 

'general,  292 

—  influence   on,    of   menstruation,   historical, 

292 

intermenstrual  fever,  293 

postmenstrual  fever,  293 

premenstrual  fever  in  consumptives,  292 

'through  subjective  symptoms,  293 

—  intermenstrual  fever  in,  293 

—  menorrhagia  in,  290 

less  common  than  amenorrhea,  288 

—  postmenstrual  fever  in,  293 

—  prem       trual  fever  in,  292 


Tuberculosis  —  Continued 

—  relation  of  menstruation  to,  288 

— -subjective  symptoms  of,  and  menstruation, 

293 
Tumors,    of   the   ovary,    uterine    hemorrhage 

due  to,  243 

—  of  the  fallopian  tubes,  uterine  hemorrhage 

due  to,  244 
— -of  generative  glands,  associated  with  pre- 
cocious menstruation,  117 

—  of  pineal  gland,  associated  with  precocious 

menstruation,  118 

—  suprarenal,     effects    of,     on     reproductive 

system,  279 
Typhoid    fever,    effect    of,    on    menstruation, 

absence  or  diminution   of  menstruation, 

294 
— - — -general  considerations,  294 

-hematometra,  295 

— ^  — peri-uterine  hematocele,  295 

—  —  uterine  bleeding  in  hemorrhagic  type  of 

typhoid,  294,  295 
variations  in,  294 

—  effects  on,  of  menstruation,  fever,  296 
-general  considerations,  295 

— - — 'influence  of  menstruation  on  treatment 

of  typhoid,  296 
— '  —  relation   of  menstrual   date  to   time  of 

onset  of  disease,  295 

—  hematometra  occurring  in,  295 

—  hemorrhagic  type  of,  with  uterine  bleed- 

ing, 294,  295 
^peri-uterine  hematocele  in,  295 

—  treatment  of,  influence  of  menstruation  on, 

296 

—  uterine  bleeding  in,  294,  295 

Umbilicus,    hemorrhage    from,    as    vicarious 

menstruation,  265 
Unconsciousness,  in  hysteria  of  menstruation, 

306 
Urates,   precipitation   of,    from  urine  of  in- 
fants,    differentiated     from     precocious 

menstruation,  118 
Urticaria,  menstrual,  308 
Uterine    adenomyoma,    uterine    hemorrhage 

due  to,  240 
Uterine  cancer.  See  Cancer;  also  Carcinoma 
Uterine    gland,    mechanical    obstruction    of, 

causing  dysmenorrhea,  192 
Uterine  fibroids,  treatment  of,  by  X-ray,  328 
Uterine    hemorrhage,    causes    of,    anatomic, 

arteriosclerosis  of  uterine  vessels,  238 

— carcinoma  of  the  uterus,  239 

— ■ ectopic  pregnancy,  242 

endometritis,  235 

—  —  —  cervical  ectropion  and  erosion,  232 
— 'hydatidiform  mole,  239 

— hyperplasia  of  the  endometrium,  235 

incomplete  abortion,  232 


356 


INDEX. 


Uterine  hemorrhage  —  Continued 

inflammatory  disease  of   the   adnexa, 

243 
— muscular  insufficiency  of   the  uterus, 

236 

polypi,  231 

sarcoma  of  the  uterus,  239 

tuberculosis  of  the  generative  organs, 

242 

^  tumors  of  the  ovary,  243 

'tumors  of  the  tubes^  244 

uterine  myoma  and  adcnomyoma,  240 

classification  of,  230 

'Constitutional,  230 

acute  infectious  diseases,  230 

■  chronic  intoxications,  231 

■ — •constitutional  diseases,  230 

organic  diseases,  231 

internal    secretory,    disorders    of    other 

endocrine  glands  than  ovary,  245 

hypersecretion  of  ovary,  244 

•  —  local  factor  in  the  endometrium,  246 

nervous,  general  considerations,  251 

^  vasomotor  disturbance  due  to  nervous 

or  psychic  influence,  251 

—  climacteric,  131,  246 

—  curettage  in  cases  associated  with  hyper- 

plasia, 248 

—  due  to  atony  of  uterine  muscle,  pituitary 

extract  in  treatment  of,  322 

—  due    to    hyperplasia    of    the    endometrium 

with     excessive    menstruation,     in     very 
young  patients,  247 

—  due  to  incomplete  abortion,  232 

clinical  considerations,  232 

•histological  findings,  233 

—  due  to  myomata,  treatment  of,  by  X-ray, 

327 

—  essential,  246 

—  functional,  246 

of  menopause,  ovarian  extract  in  treat- 
ment of,  323 

occurrence  of,  247 

of  puberty,  thyroid  extract  in  treatment 

of,  322 

— •  —  treatment  of,  256 

—  general  considerations  of,  229 

—  hyperplasia  a  constant  finding  with,  249 

—  with    hyperplasia,     ovarian    element    con- 

cerned in,  250 

—  idiopathic,  246 

—  in  influenza,  298 

—  menopausal,  131,  246 

—  of  puberty,  246 

—  relative  importance  of  anatomic  and  phys- 

iological factors,  229 

—  subservience    of    the   endometrium    to    the 

ovary,  249 

—  of  thyroid  origin,   organotherapy  for,  321 

—  treatment  of,  of  cause,  252 

—  —  constitutional,  253 


Uterine  hemorrhage  —  Continued 

— • — •by  drugs,  254 

~  —  — 'Cotarnin  phthalate,  255 

—  —  — ■  ergot,  254 

— ■ — • — -hydrastis,  255 

for  internal  administration,  255 

— • — • — ■  intra-uterine  application  of,  255 

—  — -in  functional  type;  256 

—  • — by  injections  of  blood  and  serum,  256 
— ■ — -physical,  cold  applications  to  abdomen, 

253 

—  ■ •hot  vaginal  douches,  253 

— ■ — • — •rest  in  bed,  253 

•  —  vaginal  tampons,  254 

— • — •by  radium  and  X-ray,  331 

— •in  typhoid  fever  of  hemorrhagic  type,  294, 
295 

Uterine  mucosa,  question  of  loss  of^  in  men- 
struation, 36 

Uterine  myoma,  uterine  hemorrhage  due  to, 
240 

Uterine  vessels,  arteriosclerosis  of,  uterine 
hemorrhage  due  to,  238 

Uterus,  anatomical  changes  in,  after  radi- 
ation, 329 

— •carcinoma  of.  See  Carcinoma  of  Uterus; 
also  Cancer  of  Uterus 

—  change  in,  at  puberty,  100 

— •congenital  absence  of,  amenorrhea  due  to, 
168 

—  hypoplasia  of,  amenorrhea  due  to,  169 

— •hypoplastic,    histological     reaction    of    to 

menstruation,  195 
— •infantile,  dysmenorrhea  due  to,  193 
— • — •dysmenorrhea    and    sterility    associated 

with,  194 
•preponderance   of   connective  tissue   in, 

195 
— •menstrual  cyclic  changes  in.  See  Menstrual 

Cyclic  Changes 

—  muscular  insufficiency  of,   uterine  hemor- 

rhage due  to,  236 
— •myomata  of,  pelvic  disease  due  to,  202 

—  retrodisplacement    of,    dysmenorrhea    due 

to,  201 

—  sarcoma  of,  See  Sarcoma  of  the  Uterus 
Uterus  subpubescens,  196 

"Vacillating  hj^pertension"  of  menopause, 
133 

Vagina,  anatomic  changes  in,  at  menopause, 
136 

Vaginal  discharge,  associated  with  intermen- 
strual pain,  225 

A^aginal  douches,  hot,  for  uterine  hemor- 
rhage, 253 

Vaginal  membranes,  distinguished  from 
uterine,  217 

Vaginal  tampons,  in  treatment  of  uterine 
hemorrhage,  254 

Vascular  changes  of  menstruation,  35 


INDEX. 


357' 


Vascular  factors  in  menstruation,  78 
\'ascularizalion   of   corpus  luteum,   stage   of, 

48 
Vasomotor    disturbance    due    to   nervous    or 
psychic  influence  causing  uterine  hemor- 
rhage, 251 
Vasomotor  factors  in  menstruation,  78 
Vasomotor  s3'mptoms,  of  menopause,  132 

—  organotherapy  of,  323 

—  treatment  of,  140 

Venesection,  for  vasomotor  symptoms  of 
menopause,  141 

Veronal,  dosage  of,  for  insomnia  of  meno- 
pause, 140 

Vertigo,  menstrual,  relation  of,  to  blood 
pressure,  133 

—  as  a  symptom  of  menopause,  133,  134 
Viburnum  prunifolium,  in  treatment  of  dys- 
menorrhea, 205 

Vicarious  menstruation,  "bloody  sweat,"  263 

—  cause  of,  265 

—  definition  of,  261 

—  diagnosis  of,  266 

—  incidence  of,  261 

—  menstrual  history  in  cases  of,  265 

—  during  pregnancy,  26^ 

—  sources  of  hemorrhage,  abdominal  fistulae, 

265 

cicatrices,  old,  264 

eye  and  eyelids,  264 

intestinal  canal,  26C 


Vicarious  menstruation  —  Continued 

— ■  —  kidneys,  264 

-——lips,  264 

— ■ — -lungs,  262 

— •  —  mammary  glands,  263 

-nasal  mucous  membrane,  261 

—  — 'nevi,  264 
skin,  263 

— •  —  stomach,  262 

umbilicus,  265 

-various,  265 

^  substitutional,  261 
— -  supplementary,  261 

—  terminology  of,  261 
— -treatment  of,  267 

—  types  of,  261 
Vitelline  membrane,  43 

Vulva,  anatomic  changes  in,  at  menopause, 
135 

Vulvitis,  senile,   135 

Vulvovaginitis,  senile,  of  menopause,  treat- 
ment of,  141 

Wasting  diseases,  influence  of,  on  meno- 
pause, 128 

Working  conditions,  in  hygiene  of  puberty 
109 


Zona  pellucida,  43 


(1) 


DATE  DUE 


Min/j  I) 


200 1   III 


JUNO  5  JOB 
T2!>.7nfl?  m\il 


rzirm 


mtL 


^u. 


Oue:Me. 


WOVl  1 


tor 


DEC  2)1007 


DEMCO  38-296 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RG  101  G997  1921  V.2C.1 

Menstiu.ii.uM  ,111(1  ii',  i!iM,!(!i.['. 


2002178737 


